Provider Demographics
NPI:1780624023
Name:GRANDA, ANTONIO M (MD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:M
Last Name:GRANDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-0468
Mailing Address - Country:US
Mailing Address - Phone:207-858-8353
Mailing Address - Fax:207-474-9261
Practice Address - Street 1:46 FAIRVIEW AVE STE 221
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1481
Practice Address - Country:US
Practice Address - Phone:207-474-6945
Practice Address - Fax:207-474-6933
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN09565207R00000X
OH35.143494207RG0100X
TN9565207RG0100X
MEMD23009207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3164315OtherBLUE CROSS OF TN
KY64746449Medicaid
TN104697OtherUNITED HEALTH CARE
TN378643OtherUSA - MCO
TNQ006396Medicaid
TN10074063OtherAMERIGROUP TNCARE AND AMERIVANTAGE MCR ADVANTAGE
TN1416751OtherCIGNA
TN1507235Medicaid
TN1629728OtherCOVENTRY/FIRST HEALTH
TN4066743OtherAETNA
TN1100315241OtherUSA PPO/GEHA
TN12079645OtherMULTIPLAN/PHCS
TN100014907OtherMEDICARE RR
TN1416751OtherCIGNA
KY64746449Medicaid