Organization
GRACE MEDICAL ASSOCIATION, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SMART O IDEMUDIA M.D., PHD. (OWNER)
(972) 420-6777
Entity
Organization
Contact information
Practice address
200 W. SOUTHWEST PKWY, LEWISVILLE, TX 75067
(972) 420-6777
(972) 420-0656
Mailing address
PO BOX 292128, LEWISVILLE, TX 75029-2128
(972) 420-6777
(972) 420-0656
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
J91000
TX
207R00000X
Internal Medicine Physician
Primary
J91000
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0078DM
BLUE CROSS / BLUE SHIELD
TX
05
—
138993413
—
TX
01
—
F46614
COMMERCIAL
TX
Enumeration date
06/09/2006
Last updated
06/02/2014
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