Provider Demographics
NPI:1568526952
Name:GRAHAM, TERESA ROLEEN (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ROLEEN
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 1:1000 PINE ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601
Mailing Address - Country:US
Mailing Address - Phone:541-883-1998
Mailing Address - Fax:541-850-5226
Practice Address - Street 1:1000 PINE ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601
Practice Address - Country:US
Practice Address - Phone:541-883-1998
Practice Address - Fax:541-850-5226
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19413207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR075085Medicaid
CAXPY185190OtherMEDICAL
OR075085Medicaid
G01047Medicare UPIN