Provider Demographics
NPI:1700827375
Name:GRAFF, KERRY WIDDERSHEIM (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:WIDDERSHEIM
Last Name:GRAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:PAIGE
Other - Last Name:WIDDERSHEIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:502 S MAIN ST
Mailing Address - Street 2:LAKE COUNTRY FAMILY MEDICINE
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-2242
Mailing Address - Country:US
Mailing Address - Phone:585-394-1875
Mailing Address - Fax:888-990-2283
Practice Address - Street 1:502 S MAIN ST
Practice Address - Street 2:LAKE COUNTRY FAMILY MEDICINE
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-2242
Practice Address - Country:US
Practice Address - Phone:585-394-1875
Practice Address - Fax:888-990-2283
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2076382083P0901X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000921058001OtherHEALTHNOW
NY0520OtherBLUESHIELD
NY02048819Medicaid
NYP010207638OtherEXCELLUS BC/BS AND CHP
NY101717BFOtherPREFERRED CARE
NYG58596Medicare UPIN
NY02048819Medicaid