Provider Demographics
NPI:1548306251
Name:VASCONEZ-PEREIRA, GRACE (MD, DO)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:VASCONEZ-PEREIRA
Suffix:
Gender:F
Credentials:MD, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 W 15TH ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-6471
Mailing Address - Country:US
Mailing Address - Phone:212-929-3334
Mailing Address - Fax:
Practice Address - Street 1:231 W 15TH ST APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-6471
Practice Address - Country:US
Practice Address - Phone:212-929-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02059630Medicaid
NYH14479Medicare UPIN
NY17V571Medicare ID - Type Unspecified