Provider Demographics
NPI:1689788416
Name:GRAHAM, GORDON KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:KEITH
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:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:TX
Mailing Address - Zip Code:79029-0394
Mailing Address - Country:US
Mailing Address - Phone:806-934-4979
Mailing Address - Fax:806-934-4984
Practice Address - Street 1:212 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:DUMAS
Practice Address - State:TX
Practice Address - Zip Code:79029-3806
Practice Address - Country:US
Practice Address - Phone:806-934-4979
Practice Address - Fax:806-934-4984
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3888207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G5571OtherBCBS
TXTXB161287OtherMEDICARE
TX024116OtherFIRSTCARE
TX154266403Medicaid
TX154266401Medicaid