Provider Demographics
NPI:1679548002
Name:GRANDPRE, CLARICE (MD)
Entity type:Individual
Prefix:DR
First Name:CLARICE
Middle Name:
Last Name:GRANDPRE
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:PO BOX 84945
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-4945
Mailing Address - Country:US
Mailing Address - Phone:907-374-4463
Mailing Address - Fax:907-374-7072
Practice Address - Street 1:995 ELLESMERE DR
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5759
Practice Address - Country:US
Practice Address - Phone:907-479-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2983207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0102Medicaid
AKMD0102Medicaid
AKK01WCGPDBMedicare PIN