Provider Demographics
NPI:1083963631
Name:ABU, MARY GRACE LUCAS (MD)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:LUCAS
Last Name:ABU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY GRACE
Other - Middle Name:
Other - Last Name:LUCAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:10800 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3043
Mailing Address - Country:US
Mailing Address - Phone:866-984-7483
Mailing Address - Fax:951-353-5373
Practice Address - Street 1:10800 MAGNOLIA AVE.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505
Practice Address - Country:US
Practice Address - Phone:866-984-7483
Practice Address - Fax:951-353-5375
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA136578174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist