Provider Demographics
NPI:1639130180
Name:GRAHAM, BLAKE D (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:D
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 1:1650 COCHRANE CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4613
Mailing Address - Country:US
Mailing Address - Phone:719-526-9085
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:PEDIATRICS
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-7653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054808208000000X
UT274742-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics