Provider Demographics
NPI:1043202351
Name:GRACEY, ROBERT A (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:GRACEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:JEMEZ PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87024-0279
Mailing Address - Country:US
Mailing Address - Phone:758-347-4135
Mailing Address - Fax:758-343-0225
Practice Address - Street 1:110 SHEEP SPRINGS
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024-0279
Practice Address - Country:US
Practice Address - Phone:575-834-7413
Practice Address - Fax:575-834-3022
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2020-06-23
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TX3471TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E19QMedicare PIN
T13531Medicare UPIN