Provider Demographics
NPI:1609863661
Name:GRAHAM, TIMOTHY PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PATRICK
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 1:477 COOPER RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8057
Mailing Address - Country:US
Mailing Address - Phone:380-898-8808
Mailing Address - Fax:380-898-8842
Practice Address - Street 1:477 COOPER RD STE 300
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-8057
Practice Address - Country:US
Practice Address - Phone:380-898-8808
Practice Address - Fax:380-898-8842
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-9021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H56395Medicare UPIN
OHGR40707423Medicare ID - Type Unspecified