Provider Demographics
NPI:1598740995
Name:GRACE, R RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:RANDALL
Last Name:GRACE
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 1:10930 N TATUM BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6069
Mailing Address - Country:US
Mailing Address - Phone:602-263-7600
Mailing Address - Fax:602-212-0365
Practice Address - Street 1:10930 N TATUM BLVD
Practice Address - Street 2:STE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6069
Practice Address - Country:US
Practice Address - Phone:602-263-7600
Practice Address - Fax:602-212-0365
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E00841Medicare UPIN