Provider Demographics
NPI:1740275577
Name:GRACE, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:GRACE
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:506 4TH AVE W
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-5203
Practice Address - Country:US
Practice Address - Phone:941-933-8108
Practice Address - Fax:941-933-8109
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79789OtherBCBS
FL110169974OtherRAIL ROAD MEDICARE
FLL8143OtherMEDICARE
FL379636100Medicaid
FL110169974OtherRAIL ROAD MEDICARE
FL79789OtherBCBS
79789WMedicare PIN