Provider Demographics
NPI:1851993380
Name:GRACIA, LIBERTAD IVETTE
Entity Type:Individual
Prefix:
First Name:LIBERTAD
Middle Name:IVETTE
Last Name:GRACIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:FATE
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6881
Mailing Address - Country:US
Mailing Address - Phone:214-244-5843
Mailing Address - Fax:
Practice Address - Street 1:4500 SPRING AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75210-1350
Practice Address - Country:US
Practice Address - Phone:214-865-3061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48021-PT19202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology