Provider Demographics
NPI:1679508766
Name:GRGANTO, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:GRGANTO
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 1:25 WINFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-260-0600
Mailing Address - Fax:630-260-1370
Practice Address - Street 1:25 WINFIELD ROAD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-260-0600
Practice Address - Fax:630-260-1370
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084372Medicaid
IL080153636OtherRR MEDICARE (INDIVIDUAL)
ILL71554OtherMEDICARE PTAN (INDIVIDUAL)
IL080153636OtherRR MEDICARE (INDIVIDUAL)
IL548190Medicare ID - Type UnspecifiedMEIDCARE GROUP NUMBER