Provider Demographics
NPI:1760531982
Name:GRAHAM, RONALD ARLY (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:ARLY
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:#360
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2008
Mailing Address - Country:US
Mailing Address - Phone:228-539-1771
Mailing Address - Fax:228-539-1773
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:#360
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2008
Practice Address - Country:US
Practice Address - Phone:228-539-1771
Practice Address - Fax:228-539-1773
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08736207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124410Medicaid
MS00124410Medicaid