MEDICARE: GRACE SO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A108392	CA

General Provider Information

NPI Number	:	1205169117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE SO MD

Provider Business Mailing Address
First Line	:	PO BOX 255228
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95865-5228
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 STOCKTON BLVD STE 106
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-7098
Country	:	US
Telephone Number	:	916-262-9002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2009
Last Update Date	:	12/08/2023

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