Provider Demographics
NPI:1093702003
Name:O'BRIEN, GRACE M (DO)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:M
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:DO
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 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3800
Mailing Address - Fax:801-475-3801
Practice Address - Street 1:6112 S 1550 E
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5007
Practice Address - Country:US
Practice Address - Phone:801-475-3800
Practice Address - Fax:801-475-3801
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT180186-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005193061Medicare PIN
UTE37079Medicare UPIN