Provider Demographics
NPI:1568460624
Name:GRATIANNE, ROBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:GRATIANNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 H ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-5511
Mailing Address - Country:US
Mailing Address - Phone:619-585-7227
Mailing Address - Fax:619-585-3190
Practice Address - Street 1:360 H ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5511
Practice Address - Country:US
Practice Address - Phone:619-585-7227
Practice Address - Fax:619-585-3190
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA437172084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC35563Medicare UPIN