Provider Demographics
NPI:1477818615
Name:GRAVES, ELIDA (MED)
Entity Type:Individual
Prefix:MS
First Name:ELIDA
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 5TH AVE APT 6C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-3435
Mailing Address - Country:US
Mailing Address - Phone:646-368-1619
Mailing Address - Fax:
Practice Address - Street 1:369 E 148TH ST BSMT
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4041
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY573200111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist