Provider Demographics
NPI:1215023262
Name:GRAVES, GREGORY KEITH
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:KEITH
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141174
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-1174
Mailing Address - Country:US
Mailing Address - Phone:469-622-2632
Mailing Address - Fax:
Practice Address - Street 1:1818 CORSICANA ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-6102
Practice Address - Country:US
Practice Address - Phone:214-743-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME887222084P0800X
NY2351502084P0800X
TXJ41652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105341503Medicaid
TX87050JMedicare ID - Type Unspecified
TX105341503Medicaid