Provider Demographics
NPI:1033207220
Name:GRAHAM, MARY OLIVE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:OLIVE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4536 LODGEPOLE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4702
Mailing Address - Country:US
Mailing Address - Phone:757-495-4242
Mailing Address - Fax:
Practice Address - Street 1:1020 INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-5500
Practice Address - Country:US
Practice Address - Phone:757-460-2171
Practice Address - Fax:757-460-3708
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101042914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine