Provider Demographics
NPI:1164003463
Name:GRACON, CLARA
Entity Type:Individual
Prefix:MRS
First Name:CLARA
Middle Name:
Last Name:GRACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 AMBERLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-3504
Mailing Address - Country:US
Mailing Address - Phone:216-789-3961
Mailing Address - Fax:
Practice Address - Street 1:2323 BROADVIEW RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4177
Practice Address - Country:US
Practice Address - Phone:216-661-5077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09201502156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH15083961Other15083961