Provider Demographics
NPI:1821031758
Name:GRAHAM, WALTER MAITLAND (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:MAITLAND
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 HILAND AVE
Mailing Address - Street 2:STE. L2
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2682
Mailing Address - Country:US
Mailing Address - Phone:208-677-3034
Mailing Address - Fax:208-677-2483
Practice Address - Street 1:32 S 150 E
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-5450
Practice Address - Country:US
Practice Address - Phone:208-677-3034
Practice Address - Fax:208-677-2483
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP318303Medicaid
ID5964-2OtherBLUE CROSS
ID000010002084OtherREGENCE BLUESHIELD
ID1125675Medicare ID - Type Unspecified
IDP318303Medicaid