Provider Demographics
NPI:1477567170
Name:GRAHAM, GARY R (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:R
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 1:4605 BELFORD CIR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-8110
Mailing Address - Country:US
Mailing Address - Phone:720-234-2682
Mailing Address - Fax:
Practice Address - Street 1:4605 BELFORD CIR
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-8110
Practice Address - Country:US
Practice Address - Phone:720-234-2682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2019-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 51164207QH0002X
CO39362207QH0002X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92828540Medicaid
COC810964Medicare UPIN