Provider Demographics
NPI:1083641062
Name:GRAHAM, BRADLEY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SCOTT
Last Name:GRAHAM
Suffix:
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 1:1367 DOMINION PLAZA
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-1013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1367 DOMINION PLAZA
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1013
Practice Address - Country:US
Practice Address - Phone:903-534-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1869207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8865K2OtherBLUE CROSS AND BLUE SHIELD PATHOLOGY
TX145796201Medicaid
TX070016784OtherRAILROAD MEDICARE PTAN
TX8A2682OtherBLUE CROSS AND BLUE SHIELD CLINIC
TX8865K2OtherBLUE CROSS AND BLUE SHIELD PATHOLOGY
TXF79043Medicare UPIN