Provider Demographics
NPI:1275539579
Name:GRAVES, MICHAEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:GRAVES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 YONKERS ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:79072-1820
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2404 YONKERS ST
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:TX
Practice Address - Zip Code:79072-1820
Practice Address - Country:US
Practice Address - Phone:806-293-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8602174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00GW44OtherBLUE CROSS BLUE SHIELD
TX602529OtherBLUE CROSS BLUE SHIELD KS
TX602529OtherBLUE CROSS BLUE SHIELD KS
TXA01675Medicare UPIN