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General NPI Number Information
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NPI Number | 1487695631
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Entity Type | Organization
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Legal Business Name | GRACE MEDICAL ASSOCIATION, PA
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Dates
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Enumeration Date | 06/09/2006
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Last Update Date | 06/02/2014
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Provider Practice Location Address
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Address Line | 200 W. SOUTHWEST PKWY
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City | LEWISVILLE
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State | TX
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Zip | 75067
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Country | US
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Telephone | 972-420-6777
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Fax | 972-420-0656
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Provider Business Mailing Address
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Address Line | PO BOX 292128
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City | LEWISVILLE
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State | TX
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Zip | 75029-2128
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Country | US
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Telephone | 972-420-6777
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Fax | 972-420-0656
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Authorized Official
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Title or Position | OWNER
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Name | DR. SMART O IDEMUDIA
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Credential | M.D., PHD.
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Telephone | 972-420-6777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | J91000
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | J91000
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License Number State | TX
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