Provider Demographics
NPI:1437538725
Name:BRIAN H. GRAHAM MD INC
Entity Type:Organization
Organization Name:BRIAN H. GRAHAM MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-665-2159
Mailing Address - Street 1:6455 LA JOLLA BLVD
Mailing Address - Street 2:#315
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-6627
Mailing Address - Country:US
Mailing Address - Phone:619-665-2159
Mailing Address - Fax:858-836-1159
Practice Address - Street 1:6455 LA JOLLA BLVD
Practice Address - Street 2:#315
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-6627
Practice Address - Country:US
Practice Address - Phone:619-665-2159
Practice Address - Fax:858-836-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE90629Medicaid