Provider Demographics
NPI:1619314978
Name:JERI D. GRAHAM O.D.,P.A.
Entity Type:Organization
Organization Name:JERI D. GRAHAM O.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERI
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD,PA
Authorized Official - Phone:407-263-3937
Mailing Address - Street 1:1239 SR 436
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-2707
Mailing Address - Country:US
Mailing Address - Phone:407-263-3937
Mailing Address - Fax:407-671-9656
Practice Address - Street 1:1239 SR 436
Practice Address - Street 2:SUITE 101
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-2707
Practice Address - Country:US
Practice Address - Phone:407-263-3937
Practice Address - Fax:407-671-9656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078790600Medicaid
FL1851328496OtherINDIIDUAL NPI
FL20279Medicare PIN