Healthcare Provider Details

I. General information

NPI: 1225030588
Provider Name (Legal Business Name): DAVID MICHAEL GRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 QUEEN OF PEACE DR
LAFAYETTE LA
70508-5383
US

IV. Provider business mailing address

200 CORPORATE BLVD STE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 337-354-1185
  • Fax:
Mailing address:
  • Phone: 337-354-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200024
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: