Healthcare Provider Details

I. General information

NPI: 1609841758
Provider Name (Legal Business Name): STEPHEN G GRACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9480 DOUBLE DIAMOND PKWY SUITE 105
RENO NV
89521-5845
US

IV. Provider business mailing address

9480 DOUBLE DIAMOND PKWY SUITE 105
RENO NV
89521-5845
US

V. Phone/Fax

Practice location:
  • Phone: 775-322-0515
  • Fax: 775-322-0854
Mailing address:
  • Phone: 775-322-0515
  • Fax: 775-322-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number3503
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: