Provider Demographics
NPI:1215431259
Name:CENTENO, MARY GRACE (MD)
Entity type:Individual
Prefix:DR
First Name:MARY GRACE
Middle Name:
Last Name:CENTENO
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 1:168 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1829
Mailing Address - Country:US
Mailing Address - Phone:845-486-3414
Mailing Address - Fax:
Practice Address - Street 1:168 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1829
Practice Address - Country:US
Practice Address - Phone:845-846-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311369207ZF0201X, 207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology