Provider Demographics
NPI:1043275852
Name:GRADY, VICTORIA E (MD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:E
Last Name:GRADY
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:PO BOX 419402
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9402
Mailing Address - Country:US
Mailing Address - Phone:855-290-1552
Mailing Address - Fax:336-774-6872
Practice Address - Street 1:8051 PROSPERITY WAY STE 100
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546
Practice Address - Country:US
Practice Address - Phone:804-448-0198
Practice Address - Fax:804-448-0598
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-00597207R00000X
VA0101053568207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA021044C18OtherMEDICARE PTAN
VA010339413Medicaid
VAVAA102994Medicare PIN
NCG18025Medicare UPIN