Provider Demographics
NPI:1588624555
Name:GRAF, KENNETH WALTER (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:WALTER
Last Name:GRAF
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 1:1700 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7529
Mailing Address - Country:US
Mailing Address - Phone:717-272-6621
Mailing Address - Fax:717-228-6118
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:717-228-6118
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD012811E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA175441Medicare ID - Type Unspecified
C32843Medicare UPIN