Provider Demographics
NPI:1609814227
Name:MEDESTOMAS, GRACE D (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:D
Last Name:MEDESTOMAS
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:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:NAGUABO
Mailing Address - State:PR
Mailing Address - Zip Code:00718-0918
Mailing Address - Country:US
Mailing Address - Phone:787-266-8400
Mailing Address - Fax:787-266-8386
Practice Address - Street 1:CALLE JUAN R GARZOT NUM 1
Practice Address - Street 2:LOCAL NUM 2
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718
Practice Address - Country:US
Practice Address - Phone:787-266-8400
Practice Address - Fax:787-266-8386
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15229208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR23740Medicare ID - Type Unspecified
PRI-4871Medicare UPIN