Provider Demographics
NPI:1114050655
Name:GRAHAM, DOUGLAS W (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:W
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 HOUSTON RD
Mailing Address - Street 2:STE 17
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-4884
Mailing Address - Country:US
Mailing Address - Phone:859-283-1777
Mailing Address - Fax:859-283-1703
Practice Address - Street 1:6900 HOUSTON RD
Practice Address - Street 2:STE 17
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4884
Practice Address - Country:US
Practice Address - Phone:859-283-1777
Practice Address - Fax:859-283-1703
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4583111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000112736OtherBLUE CROSS
KY85000651Medicaid
4400452OtherUNITED HEALTHCARE
2766DCOtherHUMANA
U73324Medicare UPIN
6089301Medicare ID - Type Unspecified