Provider Demographics
NPI:1306008990
Name:GRAHAM, RICHARD CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CRAIG
Last Name:GRAHAM
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 1:4635 OLSON LAKE TRL N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9530
Mailing Address - Country:US
Mailing Address - Phone:651-777-0893
Mailing Address - Fax:
Practice Address - Street 1:4635 OLSON LAKE TRL N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9530
Practice Address - Country:US
Practice Address - Phone:651-777-0893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist