Provider Demographics
NPI:1306823034
Name:DUQUE-DIZON, GRACE (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:DUQUE-DIZON
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 1:3356 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2328
Mailing Address - Country:US
Mailing Address - Phone:478-476-9642
Mailing Address - Fax:478-476-9976
Practice Address - Street 1:3356 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2328
Practice Address - Country:US
Practice Address - Phone:478-476-9642
Practice Address - Fax:478-476-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019935208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000412244KMedicaid
GAD39754Medicare UPIN
GA000412244KMedicaid