Provider Demographics
NPI:1083698146
Name:GRAHAM, ALVAN LEON JR
Entity Type:Individual
Prefix:
First Name:ALVAN
Middle Name:LEON
Last Name:GRAHAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LEON
Other - Middle Name:
Other - Last Name:GRAHAM
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-0156
Mailing Address - Country:US
Mailing Address - Phone:706-657-7559
Mailing Address - Fax:706-657-3937
Practice Address - Street 1:5377 HIGHWAY 136
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:GA
Practice Address - Zip Code:30752-2900
Practice Address - Country:US
Practice Address - Phone:706-657-7559
Practice Address - Fax:706-657-3937
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000853152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00186293AMedicaid
AL009802850Medicaid
AL08821OtherBC BS OF AL
GA410034780OtherMEDICARE RAILROAD
GA52066170-001OtherBC BS OF GA
GA621040320OtherOTHER INSURANCE
TN0049158OtherBC BS OF TN