Healthcare Provider Details

I. General information

NPI: 1083963631
Provider Name (Legal Business Name): MARY GRACE LUCAS ABU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY GRACE LUCAS MD

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE.
RIVERSIDE CA
92505
US

IV. Provider business mailing address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

V. Phone/Fax

Practice location:
  • Phone: 866-984-7483
  • Fax: 951-353-5375
Mailing address:
  • Phone: 866-984-7483
  • Fax: 951-353-5373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA136578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: