Provider Demographics
NPI:1619959624
Name:GRACIA, EDGAR I (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:I
Last Name:GRACIA
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 1:7760 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-3136
Mailing Address - Country:US
Mailing Address - Phone:915-757-7999
Mailing Address - Fax:915-757-8004
Practice Address - Street 1:7760 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-3136
Practice Address - Country:US
Practice Address - Phone:915-757-7999
Practice Address - Fax:915-757-8004
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM00952084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI23257Medicare UPIN
TX8G0920Medicare ID - Type Unspecified