Provider Demographics
NPI:1386680825
Name:CARREON, V. GRACE M (MD)
Entity Type:Individual
Prefix:DR
First Name:V. GRACE
Middle Name:M
Last Name:CARREON
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 1:8100 W 119TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-3041
Mailing Address - Country:US
Mailing Address - Phone:708-361-3300
Mailing Address - Fax:708-361-8139
Practice Address - Street 1:8100 W 119TH ST
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-3041
Practice Address - Country:US
Practice Address - Phone:708-361-3300
Practice Address - Fax:708-361-8139
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105527208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105527Medicaid