Provider Demographics
NPI:1093756249
Name:GRAHAM, TED (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
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 1:4308 ODELL LN
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-7350
Mailing Address - Country:US
Mailing Address - Phone:910-724-2194
Mailing Address - Fax:
Practice Address - Street 1:3134 BRIARCREST DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3014
Practice Address - Country:US
Practice Address - Phone:979-314-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0007207PE0004X
NC200000436207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891261NMedicaid
NCG93592Medicare UPIN
NC891261NMedicaid