Provider Demographics
NPI:1215048541
Name:GRACE, MARY E (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:GRACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:5301 F ST
Practice Address - Street 2:#220
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3226
Practice Address - Country:US
Practice Address - Phone:916-455-8000
Practice Address - Fax:916-733-6088
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG75174208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G751740Medicaid
00G751740Medicare ID - Type Unspecified
CA00G751740Medicaid