Provider Demographics
NPI:1285669739
Name:GRAVES, ANITRA SIMONE (MD)
Entity Type:Individual
Prefix:
First Name:ANITRA
Middle Name:SIMONE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 REINHARDT COLLEGE PKWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5257
Mailing Address - Country:US
Mailing Address - Phone:678-493-2527
Mailing Address - Fax:678-493-5608
Practice Address - Street 1:15 REINHARDT COLLEGE PKWY
Practice Address - Street 2:SUITE 108
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5257
Practice Address - Country:US
Practice Address - Phone:678-493-2527
Practice Address - Fax:678-492-5608
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA49799207R00000X, 207RS0012X
GA049799207RC0200X, 207RP1001X
IN01078528A207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA289374423AMedicaid
GA289374423AMedicaid