Provider Demographics
NPI:1669443198
Name:GRAHAM, JOHN DOUGLAS III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:GRAHAM
Suffix:III
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 664056
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46266-4056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5330 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6345
Practice Address - Country:US
Practice Address - Phone:317-893-1900
Practice Address - Fax:317-893-1869
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032454A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100324180AMedicaid
IN060022660Medicare PIN
IN100324180AMedicaid
IN117700CMedicare PIN