Provider Demographics
NPI:1780792051
Name:FIORENTINO, GRACE (DO)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:FIORENTINO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 876
Mailing Address - Street 2:
Mailing Address - City:ABSECON
Mailing Address - State:NJ
Mailing Address - Zip Code:08201-0876
Mailing Address - Country:US
Mailing Address - Phone:609-641-2062
Mailing Address - Fax:609-641-4633
Practice Address - Street 1:200 S NEW ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:ABSECON
Practice Address - State:NJ
Practice Address - Zip Code:08201
Practice Address - Country:US
Practice Address - Phone:609-641-2062
Practice Address - Fax:609-641-4633
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB069439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ036980X9TMedicare PIN