Provider Demographics
NPI:1154488922
Name:GRACE T. DUQUE-DIZON, MD, PC
Entity Type:Organization
Organization Name:GRACE T. DUQUE-DIZON, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:T
Authorized Official - Last Name:DUQUE DIZON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-621-0905
Mailing Address - Street 1:PO BOX 4207
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4207
Mailing Address - Country:US
Mailing Address - Phone:478-621-0905
Mailing Address - Fax:
Practice Address - Street 1:101 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-6054
Practice Address - Country:US
Practice Address - Phone:478-621-0905
Practice Address - Fax:478-742-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADB9533OtherRAIL ROAD MEDICARE GROUP
GADB9533OtherRAIL ROAD MEDICARE GROUP