Provider Demographics
NPI:1396856977
Name:GRADY, LAURA JANE (DO)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JANE
Last Name:GRADY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3419
Mailing Address - Country:US
Mailing Address - Phone:718-439-5440
Mailing Address - Fax:718-492-2776
Practice Address - Street 1:5616 6TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3419
Practice Address - Country:US
Practice Address - Phone:718-439-5440
Practice Address - Fax:718-492-2776
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH87412Medicare UPIN