Provider Demographics
NPI:1700847084
Name:GRAHAM, JON F (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:F
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 1:1380 LUSITANA ST STE 407
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2440
Mailing Address - Country:US
Mailing Address - Phone:808-550-4939
Mailing Address - Fax:808-550-2842
Practice Address - Street 1:1380 LUSITANA ST STE 407
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2440
Practice Address - Country:US
Practice Address - Phone:808-550-4939
Practice Address - Fax:808-550-2842
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD5147174400000X
CAMD-5147207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI024320Medicaid
HIC97413Medicare UPIN
HI024320Medicaid