Healthcare Provider Details

I. General information

NPI: 1093715997
Provider Name (Legal Business Name): GRACE RULLAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JR5 CALLE LIZZIE GRAHAM LEVITTOWN
TOA BAJA PR
00949-3637
US

IV. Provider business mailing address

B13 CALLE 5 PRADO ALTO
GUAYNABO PR
00966-3042
US

V. Phone/Fax

Practice location:
  • Phone: 787-784-0063
  • Fax: 787-784-0069
Mailing address:
  • Phone: 787-784-0063
  • Fax: 787-784-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number8720
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number8720
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: