Provider Demographics
NPI:1710063391
Name:GRAFTON DERMATOLOGY
Entity Type:Organization
Organization Name:GRAFTON DERMATOLOGY
Other - Org Name:LEE H GRAFTON MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-876-5000
Mailing Address - Street 1:327 BAYOU GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70364-1434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:327 BAYOU GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-1434
Practice Address - Country:US
Practice Address - Phone:985-876-5000
Practice Address - Fax:985-876-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022623332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932400OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LA1484768Medicaid
LA1441953Medicaid
LA1687421Medicaid
LA1484768Medicaid