Provider Demographics
NPI:1578561015
Name:PORTER, ANGELA M (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:M
Last Name:PORTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6820 OYSTER CV
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2051
Mailing Address - Country:US
Mailing Address - Phone:313-333-0620
Mailing Address - Fax:248-322-3071
Practice Address - Street 1:46156 WOODWARD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-5033
Practice Address - Country:US
Practice Address - Phone:248-322-6747
Practice Address - Fax:248-322-3071
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIAP064427207R00000X
MI4301064427208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483390Medicaid
MI4483390Medicaid
MIOP1694001Medicare PIN