Provider Demographics
NPI:1275858227
Name:GRACIA, JACQUELINE HEREDIA (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:HEREDIA
Last Name:GRACIA
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 1:2192 ROSITA VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE PASS
Mailing Address - State:TX
Mailing Address - Zip Code:78852-2503
Mailing Address - Country:US
Mailing Address - Phone:830-421-5349
Mailing Address - Fax:830-421-5417
Practice Address - Street 1:2192 ROSITA VALLEY RD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-2503
Practice Address - Country:US
Practice Address - Phone:830-421-5349
Practice Address - Fax:830-421-5417
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7646208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX691720OtherAMERICAN BOARD OF PEDIATRICS CERTIFICATION
TXP7646OtherTX MEDICAL BOARD PHYSICIAN FULL PERMIT