Provider Demographics
NPI:1821234816
Name:GRAGEDA, RAUL MARK MIRANDA
Entity Type:Individual
Prefix:MR
First Name:RAUL MARK
Middle Name:MIRANDA
Last Name:GRAGEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 DUNCAN STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131
Mailing Address - Country:US
Mailing Address - Phone:415-796-2900
Mailing Address - Fax:
Practice Address - Street 1:7817 OAKPORT STREET
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621
Practice Address - Country:US
Practice Address - Phone:510-638-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist