Healthcare Provider Details

I. General information

NPI: 1952396020
Provider Name (Legal Business Name): FONDA GRAVINO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 WOODLAND ST
HARTFORD CT
06105-1207
US

IV. Provider business mailing address

99 WOODLAND ST
HARTFORD CT
06105-1207
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4212
  • Fax: 860-714-8080
Mailing address:
  • Phone: 860-714-4212
  • Fax: 860-714-8080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number042931
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042931
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: