Provider Demographics
NPI:1598876328
Name:GRAHAM, ALAN DARYL (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DARYL
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:PO BOX 1067
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-1067
Mailing Address - Country:US
Mailing Address - Phone:606-878-6633
Mailing Address - Fax:606-878-5883
Practice Address - Street 1:200 CITY HILL DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-3038
Practice Address - Country:US
Practice Address - Phone:606-878-6633
Practice Address - Fax:606-878-5883
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA249363AS0400X
KY24150208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64241508Medicaid
KY64241508Medicaid
KY0678201Medicare ID - Type Unspecified