Provider Demographics
NPI:1184635286
Name:GRADY D. GAFFORD MD PC
Entity Type:Organization
Organization Name:GRADY D. GAFFORD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:STRAHOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-724-2131
Mailing Address - Street 1:15 MEADE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1813
Mailing Address - Country:US
Mailing Address - Phone:570-724-2131
Mailing Address - Fax:570-724-5471
Practice Address - Street 1:15 MEADE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1813
Practice Address - Country:US
Practice Address - Phone:570-724-2131
Practice Address - Fax:570-724-5471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000806152W00000X
PAMD025213E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001045419Medicaid
PA617798Medicare PIN
PA001045419Medicaid