Healthcare Provider Details

I. General information

NPI: 1376661371
Provider Name (Legal Business Name): THOMAS GLADSON GRACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 12/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 SPAIN RD NE
ALBUQUERQUE NM
87109-3166
US

IV. Provider business mailing address

8301 SPAIN RD NE
ALBUQUERQUE NM
87109-3166
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-6663
  • Fax: 505-823-2683
Mailing address:
  • Phone: 505-821-6663
  • Fax: 505-823-2683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberNM 77-38
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: