Provider Demographics
NPI:1295796621
Name:CANNISTRA, ANTHONY JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:CANNISTRA
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 1:333 SCHOOL ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5334
Mailing Address - Country:US
Mailing Address - Phone:401-723-1210
Mailing Address - Fax:401-312-2099
Practice Address - Street 1:333 SCHOOL ST
Practice Address - Street 2:SUITE 112
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5334
Practice Address - Country:US
Practice Address - Phone:401-723-1210
Practice Address - Fax:401-312-2099
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD08606207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJ1392902OtherMEDICARE PTAN
RI7004186Medicaid
007060918Medicare PIN
RI7004186Medicaid
RI069006280Medicare PIN
007009196Medicare ID - Type Unspecified