Provider Demographics
NPI:1790731354
Name:GHANTOUS, ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:GHANTOUS
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 1:1450 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4405
Mailing Address - Country:US
Mailing Address - Phone:203-789-6044
Mailing Address - Fax:203-789-6046
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-4290
Practice Address - Fax:203-789-6046
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035612207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001356121Medicaid
G68863Medicare UPIN
CT110007602Medicare ID - Type Unspecified