Provider Demographics
NPI:1851328496
Name:GRAHAM, JERI DEE (OPTOMETRIST)
Entity Type:Individual
Prefix:DR
First Name:JERI
Middle Name:DEE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OPTOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 STATE ROAD 436 STE 101
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-6447
Mailing Address - Country:US
Mailing Address - Phone:407-263-3937
Mailing Address - Fax:407-671-9656
Practice Address - Street 1:1239 STATE ROAD 436 STE 101
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-6447
Practice Address - Country:US
Practice Address - Phone:407-263-3937
Practice Address - Fax:407-671-9656
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078790600Medicaid
FLU19999Medicare UPIN
FL20279Medicare PIN