Provider Demographics
NPI:1649483645
Name:HIPOLITO, MARY GRACE (MD)
Entity type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:HIPOLITO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:560 GAGE BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-942-3286
Practice Address - Fax:509-628-1354
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00047814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1649483645Medicaid
WA1649483645Medicaid