Provider Demographics
NPI:1053343764
Name:CRITTENDEN, GRACE (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:
Last Name:CRITTENDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E. CHURCH STREET
Mailing Address - Street 2:ATTENTION: MEDICAL STAFF OFFICE
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-739-3954
Mailing Address - Fax:
Practice Address - Street 1:1250 PEACH ST STE B
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-543-4043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65487207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB234888OtherMEDICARE ID
CA00G54870Medicaid
110216081Medicare PIN
WG65487BMedicare PIN