Provider Demographics
NPI:1265410013
Name:ELIAS, GRACE S (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:S
Last Name:ELIAS
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 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-782-3796
Mailing Address - Fax:951-784-3263
Practice Address - Street 1:7117 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2615
Practice Address - Country:US
Practice Address - Phone:951-782-3796
Practice Address - Fax:951-784-3263
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45811208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31887ZOtherGROUP PTAN
00G458110Medicare ID - Type Unspecified
CAZZZ31887ZOtherGROUP PTAN