Provider Demographics
NPI:1376525253
Name:GRAHAM, ANDRE DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:DEAN
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 1:800 8TH AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2602
Mailing Address - Country:US
Mailing Address - Phone:682-224-3748
Mailing Address - Fax:682-841-0039
Practice Address - Street 1:117 JANE LN
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:TX
Practice Address - Zip Code:76645-2673
Practice Address - Country:US
Practice Address - Phone:682-224-3748
Practice Address - Fax:682-841-0039
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228186208600000X
TXM5731208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BR115OtherBCBS
TX185966202Medicaid
TX185966203Medicaid
TX185966203Medicaid
TX8L2766Medicare PIN
TXTXB101423Medicare PIN
TX8L5638Medicare PIN