Provider Demographics
NPI:1093121816
Name:JEONG, GRACE EUNHYE (OD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:EUNHYE
Last Name:JEONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COLISEUM AVE
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-3292
Mailing Address - Country:US
Mailing Address - Phone:603-882-9800
Mailing Address - Fax:603-882-0556
Practice Address - Street 1:1353 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2932
Practice Address - Country:US
Practice Address - Phone:617-288-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3102027Medicaid