Provider Demographics
NPI:1790893048
Name:GRAHAM, JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-8651
Mailing Address - Country:US
Mailing Address - Phone:518-371-5422
Mailing Address - Fax:518-371-2063
Practice Address - Street 1:21 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-8651
Practice Address - Country:US
Practice Address - Phone:518-371-5422
Practice Address - Fax:518-371-2063
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX3A141OtherEMPIRE BC/BS
NY10035363OtherCDPHP
NY98L1853OtherMVP
NYC02183-4OtherWORKER COMPENSATION
NYC02183-4OtherWORKER COMPENSATION