Provider Demographics
NPI:1225096860
Name:GRAHAM, JOSEPH A (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DO
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 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1300
Mailing Address - Fax:228-867-6423
Practice Address - Street 1:1340 BROAD AVENUE
Practice Address - Street 2:SUITE 220
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-575-1300
Practice Address - Fax:228-867-6423
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL059594208600000X
MS203502086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2977616OtherCIGNA PROVIDER #
FL53064OtherBCBS PROVIDER #
MS5108802Medicaid
FL7616821OtherAETNA PROVIDER #
FL276169600Medicaid
MS5108802Medicaid
FLU8279XMedicare PIN