Provider Demographics
NPI:1417481631
Name:RAZAVIAN, GRACE K
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:K
Last Name:RAZAVIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 CARE WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8425
Mailing Address - Country:US
Mailing Address - Phone:540-374-3131
Mailing Address - Fax:
Practice Address - Street 1:1051 CARE WAY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8425
Practice Address - Country:US
Practice Address - Phone:540-374-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101279258208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology