Provider Demographics
NPI:1538120092
Name:GRAHAM, FITZROY HENRY (MD)
Entity Type:Individual
Prefix:
First Name:FITZROY
Middle Name:HENRY
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 1:105 MIRRAMONT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8214
Mailing Address - Country:US
Mailing Address - Phone:770-485-9670
Mailing Address - Fax:678-401-7658
Practice Address - Street 1:105 MIRRAMONT LAKE DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8214
Practice Address - Country:US
Practice Address - Phone:770-485-9670
Practice Address - Fax:678-401-7658
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048780208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000919663BMedicaid