Provider Demographics
NPI:1831132265
Name:GRAHAM, DONALD R (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:R
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 1:127 DEL PRADO ST
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1313
Mailing Address - Country:US
Mailing Address - Phone:503-680-6450
Mailing Address - Fax:
Practice Address - Street 1:342 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1917
Practice Address - Country:US
Practice Address - Phone:503-873-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10678207PE0004X
VA0101048920207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010056161Medicaid
OR238246Medicaid
VA010056161Medicaid
VA930019862Medicare PIN
ORD86755Medicare UPIN
VAD86755Medicare UPIN
VA9330000717Medicare PIN
VAG01425F11Medicare PIN