Basic Information
| Provider Information | |||||||||
| NPI: | 1659577518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE JESUS | ||||||||
| FirstName: | GRACIELA | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 RICE HOPE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294649275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875659265 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 BEE STREET | ||||||||
| Address2: | MEDICAL SERVICE (111) RALPH H. JOHNSONVA MEDICAL CENTER | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | 33701 | SC | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207N00000X | 33701 | SC | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.