Provider Demographics
NPI:1174607105
Name:GORANITIS, IRENE (MD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:GORANITIS
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 1:126 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1441
Mailing Address - Country:US
Mailing Address - Phone:781-326-6005
Mailing Address - Fax:781-326-1736
Practice Address - Street 1:126 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1441
Practice Address - Country:US
Practice Address - Phone:781-326-6005
Practice Address - Fax:781-326-1736
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6183794Medicare ID - Type Unspecified
MAA57106Medicare UPIN