Provider Demographics
NPI:1497721682
Name:ANTOINE, GREGORY A (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:ANTOINE
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 1:850 HARRISON AVE
Mailing Address - Street 2:YACC BN C7
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 HARRISON AVE
Practice Address - Street 2:SUITE 9400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2371
Practice Address - Country:US
Practice Address - Phone:617-638-8419
Practice Address - Fax:617-638-8412
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209930208200000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110004320AMedicaid
MA110004320AMedicaid
MAD43384Medicare UPIN
MARX0648Medicare PIN