Provider Demographics
NPI:1487231403
Name:CORONICA, GRANT (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:CORONICA
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 1:429 HWY 79
Mailing Address - Street 2:
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-9800
Mailing Address - Country:US
Mailing Address - Phone:732-263-7970
Mailing Address - Fax:
Practice Address - Street 1:429 RTE 79
Practice Address - Street 2:STE 1
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751
Practice Address - Country:US
Practice Address - Phone:732-263-7970
Practice Address - Fax:732-263-7971
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA12141600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22-3471515Medicaid