Provider Demographics
NPI:1578797643
Name:GRAVES, VENSON MATTHEW (IDC)
Entity Type:Individual
Prefix:MR
First Name:VENSON
Middle Name:MATTHEW
Last Name:GRAVES
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS THEODORE ROOSEVELT # 71
Mailing Address - Street 2:CVN-71
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09599-2871
Mailing Address - Country:US
Mailing Address - Phone:757-446-7633
Mailing Address - Fax:
Practice Address - Street 1:USS THEODORE ROOSEVELT # 71
Practice Address - Street 2:CVN-71
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09599-2871
Practice Address - Country:US
Practice Address - Phone:757-446-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No246QC2700XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyCytotechnology
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist