Provider Demographics
NPI:1730119751
Name:COVARRUBIAS, GRACIA (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACIA
Middle Name:
Last Name:COVARRUBIAS
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 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: MCMF - CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31001 RANCHO VIEJO RD.
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:949-661-9611
Practice Address - Fax:949-443-6200
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A943240Medicaid
CA00A943240Medicaid
CAEN837ZMedicare PIN
CA00A943240Medicaid