Provider Demographics
NPI:1497378046
Name:JANG, GRACE K (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:K
Last Name:JANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:K
Other - Last Name:SUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PROVIDER ENROLLMENT 41 MALL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 TOZER RD STE 202
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5514
Practice Address - Country:US
Practice Address - Phone:978-927-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN69675207Q00000X
MN30810207Q00000X
MA1016183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine