Provider Demographics
NPI:1619946423
Name:PORRETTA, ANTHONY C (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:C
Last Name:PORRETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29990 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3225
Mailing Address - Country:US
Mailing Address - Phone:248-538-6463
Mailing Address - Fax:248-538-6470
Practice Address - Street 1:29990 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3225
Practice Address - Country:US
Practice Address - Phone:248-538-6463
Practice Address - Fax:248-538-6470
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028456173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4406532Medicaid
MIOM88850Medicare ID - Type Unspecified
MI4406532Medicaid
MIA73710Medicare UPIN