Provider Demographics
NPI:1649234139
Name:GRACE, CAROL (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:GRACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1834 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-2522
Mailing Address - Country:US
Mailing Address - Phone:760-789-2629
Mailing Address - Fax:
Practice Address - Street 1:1834 MAIN ST
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2522
Practice Address - Country:US
Practice Address - Phone:760-789-2629
Practice Address - Fax:760-788-3235
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84833207Q00000X
NJ25MA11155800207Q00000X
AL00025976207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009968725Medicaid
MS03627051Medicaid
MS03627051Medicaid
AL051522664Medicare ID - Type Unspecified