Healthcare Provider Details

I. General information

NPI: 1972676930
Provider Name (Legal Business Name): RICHARD IAN GRACER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 NORRIS CANYON RD SUITE 102
SAN RAMON CA
94583-5406
US

IV. Provider business mailing address

5401 NORRIS CANYON RD SUITE 102
SAN RAMON CA
94583-5406
US

V. Phone/Fax

Practice location:
  • Phone: 925-277-1100
  • Fax: 925-277-1263
Mailing address:
  • Phone: 925-277-1100
  • Fax: 925-277-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG35367
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG35367
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG35367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: