Provider Demographics
NPI:1083680060
Name:GRAHAM, STUART NATHAN (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:NATHAN
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:PO BOX 28199
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0199
Mailing Address - Country:US
Mailing Address - Phone:858-613-8900
Mailing Address - Fax:
Practice Address - Street 1:15611 POMERADO RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2437
Practice Address - Country:US
Practice Address - Phone:858-675-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70035208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF38986Medicare UPIN