Provider Demographics
NPI:1093740599
Name:NIKLAS, GRACE (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:NIKLAS
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 1:210 WHITING ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-3724
Mailing Address - Country:US
Mailing Address - Phone:781-749-6131
Mailing Address - Fax:781-749-6167
Practice Address - Street 1:210 WHITING ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-3724
Practice Address - Country:US
Practice Address - Phone:781-749-6131
Practice Address - Fax:781-749-6167
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA50515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3000010Medicaid
NCIJ03771Medicare ID - Type Unspecified
MA3000010Medicaid