Healthcare Provider Details

I. General information

NPI: 1740926286
Provider Name (Legal Business Name): GRACE ELAINE RIVERA OWEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

6 SUNDANCE LN
BOW NH
03304-4908
US

V. Phone/Fax

Practice location:
  • Phone: 617-643-0707
  • Fax:
Mailing address:
  • Phone: 603-724-1456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1023652
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: