Provider Demographics
NPI:1972676930
Name:GRACER, RICHARD IAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:IAN
Last Name:GRACER
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 1:5401 NORRIS CANYON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5406
Mailing Address - Country:US
Mailing Address - Phone:925-277-1100
Mailing Address - Fax:925-277-1263
Practice Address - Street 1:5401 NORRIS CANYON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5406
Practice Address - Country:US
Practice Address - Phone:925-277-1100
Practice Address - Fax:925-277-1263
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35367207QA0401X, 207QA0505X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA756081627Medicare PIN
CADJ929ZMedicare PIN
CAA46328Medicare UPIN
CA00G353670Medicare ID - Type UnspecifiedINDIVIDUAL ID