Provider Demographics
NPI:1659667293
Name:GRACE, MIRA (MD)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:GRACE
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 1:24 FRANK LLOYD WRIGHT DRIVE
Mailing Address - Street 2:SUITE J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:951-486-5611
Mailing Address - Fax:951-486-5620
Practice Address - Street 1:44428 WOODWARD AVENUE SUITE 102
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5009
Practice Address - Country:US
Practice Address - Phone:734-712-8700
Practice Address - Fax:734-622-5017
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301507706207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program