Healthcare Provider Details

I. General information

NPI: 1083057491
Provider Name (Legal Business Name): VICTORIA GRASSO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

IV. Provider business mailing address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

V. Phone/Fax

Practice location:
  • Phone: 575-532-4419
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA-2215-19
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberQ7379
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: