Provider Demographics
NPI:1457464778
Name:GRAHAM, KENNETH B
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 NORTHERN BLVD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-466-0390
Mailing Address - Fax:516-829-0520
Practice Address - Street 1:600 NORTHERN BLVD
Practice Address - Street 2:SUITE 216
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-466-0390
Practice Address - Fax:516-829-0520
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224987207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291707Medicaid
NY423B91Medicare ID - Type Unspecified
NYW8E001Medicare PIN
NY01556PMedicare PIN
NY01556Medicare PIN
NYCF7254Medicare PIN
NY180045709Medicare PIN
G65632Medicare UPIN
NYCA4489Medicare PIN
NY180045710Medicare PIN