Provider Demographics
NPI:1639165988
Name:CANNISTRARO, PAUL A (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:CANNISTRARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 ARROW ST STE 210
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5105
Mailing Address - Country:US
Mailing Address - Phone:617-460-1053
Mailing Address - Fax:617-848-9485
Practice Address - Street 1:12 ARROW ST STE 210
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5105
Practice Address - Country:US
Practice Address - Phone:617-460-1053
Practice Address - Fax:617-848-9485
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2158922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2042291Medicaid
MA469409OtherTUFTS HEALTH PLAN
MAJ27378OtherBLUE CROSS BLUE SHIELD
MAA36821Medicare ID - Type Unspecified
MAI07670Medicare UPIN