Provider Demographics
NPI:1033172432
Name:GRAVES, CHARLES G III (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:G
Last Name:GRAVES
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 E MCMAHON RD
Mailing Address - Street 2:
Mailing Address - City:HAYDEN LAKE
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9587
Mailing Address - Country:US
Mailing Address - Phone:208-772-0915
Mailing Address - Fax:
Practice Address - Street 1:5925 E MCMAHON RD
Practice Address - Street 2:
Practice Address - City:HAYDEN LAKE
Practice Address - State:ID
Practice Address - Zip Code:83835-9587
Practice Address - Country:US
Practice Address - Phone:208-772-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5893207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000325600Medicaid
ID1125291Medicare PIN
ID000325600Medicaid