Provider Demographics
NPI:1841227774
Name:GRACIAS, VICENTE H (MD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:H
Last Name:GRACIAS
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 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:SUITE 4100
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-7920
Practice Address - Fax:732-235-7079
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063973L2086S0102X
NJ25MA08592500208600000X, 2086S0127X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017085020001Medicaid
NJ7673302Medicaid
NJP01069324OtherRAILROAD MEDICARE
NJ7673302Medicaid
NJ163864A00Medicare PIN
PA014680Medicare ID - Type Unspecified
NJP01069324OtherRAILROAD MEDICARE