Provider Demographics
NPI:1124361209
Name:GRACEY MANIAR, LIA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:LIA
Middle Name:
Last Name:GRACEY MANIAR
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:DR
Other - First Name:LIA
Other - Middle Name:
Other - Last Name:GRACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PKWY STE 270
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78738-1796
Practice Address - Country:US
Practice Address - Phone:512-654-0270
Practice Address - Fax:512-654-0271
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR2860207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program