Provider Demographics
NPI:1053441477
Name:GRAVES, ROBERT L (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:GRAVES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 RESERVOIR AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-6068
Mailing Address - Country:US
Mailing Address - Phone:401-942-3330
Mailing Address - Fax:401-942-3833
Practice Address - Street 1:1150 RESERVOIR AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-6068
Practice Address - Country:US
Practice Address - Phone:401-942-3330
Practice Address - Fax:401-942-3833
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2148207R00000X, 207Q00000X
RIDO00688207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME102170206Medicaid
MO242694024Medicaid
RIRG86689Medicaid
RIRG86689Medicaid
ME102170206Medicaid
MO242694024Medicaid