Provider Demographics
NPI:1821032095
Name:GRAHAM, JOHN W (PT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:W
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 S DELSEA DR STE C
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5306
Mailing Address - Country:US
Mailing Address - Phone:856-690-1616
Mailing Address - Fax:856-690-1089
Practice Address - Street 1:298 S DELSEA DR
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-4568
Practice Address - Country:US
Practice Address - Phone:856-690-1616
Practice Address - Fax:856-690-1089
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00514500174400000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ092122AQVMedicare PIN