Provider Demographics
NPI:1447239629
Name:GRAHAM, KELLY LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LEIGH
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-2269
Mailing Address - Country:US
Mailing Address - Phone:479-474-7878
Mailing Address - Fax:479-471-1476
Practice Address - Street 1:113 N PLAZA CT
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2269
Practice Address - Country:US
Practice Address - Phone:479-474-7878
Practice Address - Fax:479-471-1476
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2380152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR171400722Medicaid
AR171400722Medicaid
ARU05263Medicare UPIN