Provider Demographics
NPI:1396929444
Name:TOTAL GRACE PEDIATRICS P.C.
Entity type:Organization
Organization Name:TOTAL GRACE PEDIATRICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BASHIRU
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAWODU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-292-8103
Mailing Address - Street 1:900 N HAIRSTON RD # RS
Mailing Address - Street 2:SUITE A
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2857
Mailing Address - Country:US
Mailing Address - Phone:404-292-8103
Mailing Address - Fax:404-292-8105
Practice Address - Street 1:900 N HAIRSTON RD # RS
Practice Address - Street 2:SUITE A
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2857
Practice Address - Country:US
Practice Address - Phone:404-292-8103
Practice Address - Fax:404-292-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0521622080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty