Provider Demographics
NPI:1295723955
Name:ANGELO, MICHAEL ALON (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALON
Last Name:ANGELO
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 1:4438 VIKING DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-7510
Mailing Address - Country:US
Mailing Address - Phone:318-918-0015
Mailing Address - Fax:318-963-0015
Practice Address - Street 1:1000 CHINABERRY DR STE 800
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2455
Practice Address - Country:US
Practice Address - Phone:318-392-3372
Practice Address - Fax:318-392-3373
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486434Medicaid
LA5H401Medicare ID - Type Unspecified
H18623Medicare UPIN