Provider Demographics
NPI:1578567012
Name:GRAHAM, AUTUMN C (MD)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:C
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 1:330 S WEST ST
Mailing Address - Street 2:APT 308
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-5915
Mailing Address - Country:US
Mailing Address - Phone:703-254-7237
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2976
Practice Address - Country:US
Practice Address - Phone:202-444-2116
Practice Address - Fax:513-557-3332
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085236207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCJ8790001OtherBLUE SHIELD
DCP00350406OtherRAILROAD MED
MD75859902OtherBLUE SHIELD
DC017465M32Medicare PIN
MD75859902OtherBLUE SHIELD
DCP00350406OtherRAILROAD MED