Provider Demographics
NPI:1245396266
Name:GRAHAM, KENNETH R, II (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R,
Last Name:GRAHAM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2419
Mailing Address - Country:US
Mailing Address - Phone:203-621-3764
Mailing Address - Fax:203-621-3701
Practice Address - Street 1:1351 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2419
Practice Address - Country:US
Practice Address - Phone:203-621-3764
Practice Address - Fax:203-621-3701
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0466392084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0042335926Medicaid
NY286622OtherHEALTHNET
NY285BN1Medicare PIN