Provider Demographics
NPI:1144273004
Name:LIN FU, GRACIE MIN-MEI (MD)
Entity type:Individual
Prefix:MRS
First Name:GRACIE
Middle Name:MIN-MEI
Last Name:LIN FU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:GRACIE
Other - Middle Name:MIN-MEI
Other - Last Name:LIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6636 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5967
Mailing Address - Country:US
Mailing Address - Phone:716-633-0542
Mailing Address - Fax:716-633-0543
Practice Address - Street 1:6636 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5967
Practice Address - Country:US
Practice Address - Phone:716-633-0542
Practice Address - Fax:716-633-0543
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010105201OtherUNIVERA
NY000511291001OtherCOMMUNITY BLUE
NY0104154OtherINDEPENDENT HEALTH
NY01343508Medicaid
NY0104154OtherINDEPENDENT HEALTH
NY01343508Medicaid