Provider Demographics
NPI:1376661371
Name:GRACE, THOMAS GLADSON (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GLADSON
Last Name:GRACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 SPAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3166
Mailing Address - Country:US
Mailing Address - Phone:505-821-6663
Mailing Address - Fax:505-823-2683
Practice Address - Street 1:8301 SPAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3166
Practice Address - Country:US
Practice Address - Phone:505-821-6663
Practice Address - Fax:505-823-2683
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 77-38174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00016071Medicaid
NMNM007588OtherBC/BS OF NM
NMD35664Medicare UPIN
NM00016071Medicaid