Provider Demographics
NPI:1235135518
Name:GRADY, YOLANDA T (MD)
Entity type:Individual
Prefix:DR
First Name:YOLANDA
Middle Name:T
Last Name:GRADY
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 1:13768 ROSWELL AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-1401
Mailing Address - Country:US
Mailing Address - Phone:909-628-4205
Mailing Address - Fax:909-628-4875
Practice Address - Street 1:13768 ROSWELL AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-1401
Practice Address - Country:US
Practice Address - Phone:909-628-4205
Practice Address - Fax:909-628-4875
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-04-21
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
CAA53673207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A536730Medicaid
CAI22407Medicare UPIN
CAZZZ31642ZMedicare ID - Type UnspecifiedPROVIDER IDENTIFACTION NU
CA1952497513Medicare PIN