Provider Demographics
NPI:1497948087
Name:MONTENEGRO, GRACE A (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:A
Last Name:MONTENEGRO
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 1:1008 S SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-3530
Mailing Address - Fax:
Practice Address - Street 1:1008 S SPRING AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2520
Practice Address - Country:US
Practice Address - Phone:314-977-3530
Practice Address - Fax:314-977-1630
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017017208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery