Provider Demographics
NPI:1538123674
Name:GRAHAM, MARTIN LAREN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LAREN
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 1:7424 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8120
Mailing Address - Country:US
Mailing Address - Phone:253-841-4353
Mailing Address - Fax:253-581-5698
Practice Address - Street 1:222 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3754
Practice Address - Country:US
Practice Address - Phone:253-841-4353
Practice Address - Fax:253-581-5698
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010306162085R0202X
WAMD000123032085R0202X
CAA240392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8194904Medicaid
WA74116OtherL&I
WA8194904Medicaid
WA74116OtherL&I