Provider Demographics
NPI:1639287949
Name:GRAHAM, DONALD (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 MERCHANTS WAY
Mailing Address - Street 2:SUITE 401
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0867
Mailing Address - Country:US
Mailing Address - Phone:912-871-7777
Mailing Address - Fax:912-871-7172
Practice Address - Street 1:1211 MERCHANTS WAY
Practice Address - Street 2:SUITE 401
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0867
Practice Address - Country:US
Practice Address - Phone:912-871-7777
Practice Address - Fax:912-871-7172
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057629174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE71425Medicare UPIN
GA14BDHLGMedicare ID - Type Unspecified