Provider Demographics
NPI:1124216353
Name:CHARLES E GRAHAM MD LTD
Entity Type:Organization
Organization Name:CHARLES E GRAHAM MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-733-6673
Mailing Address - Street 1:PO BOX 34405
Mailing Address - Street 2:3435 W CRAIG RD SUITE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-4405
Mailing Address - Country:US
Mailing Address - Phone:702-733-6673
Mailing Address - Fax:702-633-0077
Practice Address - Street 1:3435 W CRAIG RD STE A
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5116
Practice Address - Country:US
Practice Address - Phone:702-733-6673
Practice Address - Fax:702-633-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV36777Medicare PIN