Provider Demographics
NPI:1518921642
Name:GRAHAM, MARLON A (MD)
Entity Type:Individual
Prefix:
First Name:MARLON
Middle Name:A
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 1:700 UNIVERSITY CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2706
Mailing Address - Country:US
Mailing Address - Phone:540-961-8388
Mailing Address - Fax:540-322-1847
Practice Address - Street 1:401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-1588
Practice Address - Country:US
Practice Address - Phone:540-838-8000
Practice Address - Fax:540-904-0051
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010395372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA178300OtherANTHEM
VA01455137OtherAMERIGROUP
VA179156OtherANTHEM
VA179154OtherANTHEM
VA552451OtherVALUE OPTIONS
VA004945298Medicaid
VA179154OtherANTHEM
VA178300OtherANTHEM
009113M23Medicare PIN
007193M13Medicare PIN
009756M94Medicare PIN
VA004945298Medicaid