Healthcare Provider Details

I. General information

NPI: 1043202351
Provider Name (Legal Business Name): ROBERT A GRACEY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date: 03/27/2006
Reactivation Date: 03/28/2006

III. Provider practice location address

110 SHEEP SPRINGS
JEMEZ PUEBLO NM
87024-0279
US

IV. Provider business mailing address

PO BOX 279
JEMEZ PUEBLO NM
87024-0279
US

V. Phone/Fax

Practice location:
  • Phone: 575-834-7413
  • Fax: 575-834-3022
Mailing address:
  • Phone: 758-347-4135
  • Fax: 758-343-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3471TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: