Provider Demographics
NPI:1053382259
Name:GRAVELY, VONDA K (MD)
Entity type:Individual
Prefix:DR
First Name:VONDA
Middle Name:K
Last Name:GRAVELY
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 1:124 MALLARD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-4046
Mailing Address - Country:US
Mailing Address - Phone:864-241-1040
Mailing Address - Fax:
Practice Address - Street 1:250 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3009
Practice Address - Country:US
Practice Address - Phone:864-585-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC211072084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905213Medicaid
SC211078Medicaid
SCC7069OtherMEDCOST
SCP00047008Medicare PIN
SCC7069OtherMEDCOST
SCH37909Medicare PIN