Provider Demographics
NPI:1073589628
Name:GRANFONE, ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:
Last Name:GRANFONE
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:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:781-485-1000
Mailing Address - Fax:781-286-5418
Practice Address - Street 1:300 BROADWAY RHC
Practice Address - Street 2:REVERE HEALTH CENTER BROADWAY
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5035
Practice Address - Country:US
Practice Address - Phone:781-485-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA48781207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ05333OtherBCBS MA
MA3010261Medicaid
MA716085OtherTUFTS HEALTH PLAN
MAJ05333Medicare ID - Type Unspecified
MA3010261Medicaid