Provider Demographics
NPI:1609892553
Name:DEBOCCARDO, GRACIELA O (MD)
Entity type:Individual
Prefix:
First Name:GRACIELA
Middle Name:O
Last Name:DEBOCCARDO
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 1:2852 TAMIAMI TRL STE 1
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5100
Mailing Address - Country:US
Mailing Address - Phone:941-505-8720
Mailing Address - Fax:941-505-8747
Practice Address - Street 1:2852 TAMIAMI TRL STE 1
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5100
Practice Address - Country:US
Practice Address - Phone:941-505-8720
Practice Address - Fax:941-505-8747
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134410207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01126618Medicaid
NJ0591181Medicaid