Provider Demographics
NPI:1154827061
Name:DE JONG, GRACIA (MD)
Entity Type:Individual
Prefix:
First Name:GRACIA
Middle Name:
Last Name:DE JONG
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 1:55 CLAIREDAN DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8064
Mailing Address - Country:US
Mailing Address - Phone:614-888-8989
Mailing Address - Fax:614-888-8968
Practice Address - Street 1:55 CLAIREDAN DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-8064
Practice Address - Country:US
Practice Address - Phone:614-888-8989
Practice Address - Fax:614-888-8968
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-01
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.141481208000000X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH771400OtherCGS MEDICARE
OH0435440Medicaid