Provider Demographics
NPI:1669461794
Name:GRAHAM, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
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 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:811 E PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3258
Practice Address - Country:US
Practice Address - Phone:270-688-2163
Practice Address - Fax:812-471-6650
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22937207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64229370Medicaid
KY64229370Medicaid
KS0086504Medicare ID - Type Unspecified