Provider Demographics
NPI:1750321329
Name:GRAVES, JEFFERY R (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:R
Last Name:GRAVES
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:6801 DIXIE HWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3913
Mailing Address - Country:US
Mailing Address - Phone:502-361-6617
Mailing Address - Fax:502-361-6637
Practice Address - Street 1:1850 BLUEGRASS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1161
Practice Address - Country:US
Practice Address - Phone:502-361-6617
Practice Address - Fax:502-361-6637
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY25884207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64258841Medicaid
KY050069688OtherRR MEDICARE
IN200437780Medicaid
KY64258841Medicaid
0609008Medicare Oscar/Certification