Provider Demographics
NPI:1780784603
Name:GRISANTI, KATHLEEN (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:GRISANTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2749
Mailing Address - Country:US
Mailing Address - Phone:716-636-5437
Mailing Address - Fax:716-636-5439
Practice Address - Street 1:1800 MAPLE RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14221-2749
Practice Address - Country:US
Practice Address - Phone:716-636-5437
Practice Address - Fax:716-636-5439
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1765262080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01302767Medicaid
NY00020033001OtherUNIVERA
NY000529416001OtherBC/BS
NY040426000946OtherFIDELIS
NY0014387840001OtherPA MEDICAID
NY3905807OtherIHA
NY01302767Medicaid
NY3905807OtherIHA