Provider Demographics
NPI:1558343616
Name:GRACE, MICHAEL L (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:GRACE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:819 IRA E WOODS AVE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-4012
Practice Address - Country:US
Practice Address - Phone:817-488-4893
Practice Address - Fax:817-488-5939
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2710TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80FDOtherBLUE CROSS BLUE SHIELD
TXE15AOtherBLUE CROSS BLUE SHIELD
TXP00693823OtherMEDICARE RR
TX00E15AMedicare PIN
TXTXB148287Medicare PIN
TXTXB148286Medicare PIN
TXE15AOtherBLUE CROSS BLUE SHIELD
TX80FDOtherBLUE CROSS BLUE SHIELD
TXU49927Medicare UPIN