Provider Demographics
NPI:1508920661
Name:GRAHAM, JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:HESPERUS
Mailing Address - State:CO
Mailing Address - Zip Code:81326-9752
Mailing Address - Country:US
Mailing Address - Phone:970-259-7136
Mailing Address - Fax:
Practice Address - Street 1:4801 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6002
Practice Address - Country:US
Practice Address - Phone:505-324-8375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ2833Medicaid
CO84-1497491-001OtherROCKY MT HMO
NMNM012425OtherBLUE CROSS BLUE SHIELD NM
NMNM012425OtherBLUE CROSS BLUE SHIELD NM