Provider Demographics
NPI:1790778520
Name:GRAHAM, STEPHEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9983 E DESERT TRAIL LN
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-4922
Mailing Address - Country:US
Mailing Address - Phone:064-251-3554
Mailing Address - Fax:801-618-4185
Practice Address - Street 1:9983 E DESERT TRAIL LN
Practice Address - Street 2:
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-4922
Practice Address - Country:US
Practice Address - Phone:406-425-1355
Practice Address - Fax:801-618-4185
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT184400-1205207W00000X, 208D00000X
AZ19987207W00000X, 208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ508021Medicaid
UTB97946Medicare UPIN