Healthcare Provider Details

I. General information

NPI: 1841227774
Provider Name (Legal Business Name): VICENTE H GRACIAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATERSON ST SUITE 4100
NEW BRUNSWICK NJ
08901-1962
US

IV. Provider business mailing address

66 W GILBERT ST 2ND FLOOR
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-7920
  • Fax: 732-235-7079
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD063973L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA08592500
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number25MA08592500
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number25MA08592500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: