Provider Demographics
NPI:1033160924
Name:FEDERMAN, GRACE L (MD)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:L
Last Name:FEDERMAN
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 1:25 TAMARACK AVE
Mailing Address - Street 2:ADVANCED DERM CARE PC
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811
Mailing Address - Country:US
Mailing Address - Phone:203-797-8990
Mailing Address - Fax:203-743-2199
Practice Address - Street 1:25 TAMARACK AVE
Practice Address - Street 2:ADVANCED DERM CARE PC
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811
Practice Address - Country:US
Practice Address - Phone:203-797-8990
Practice Address - Fax:203-743-2199
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033025207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1330258Medicaid
110004884Medicare ID - Type Unspecified
CT1330258Medicaid