Provider Demographics
NPI:1275579088
Name:GRACIOUS, BARBARA L (MD)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:L
Last Name:GRACIOUS
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:DEPT 781625
Mailing Address - Street 2:PO BOX 78000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1625
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-2220
Practice Address - Street 1:495 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5679
Practice Address - Country:US
Practice Address - Phone:614-355-8007
Practice Address - Fax:614-355-8620
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0757922084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid
OH0108229Medicaid