Provider Demographics
NPI:1861631293
Name:MCGRAW, BRANDI NICHOLE SMITH (OD)
Entity Type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:NICHOLE SMITH
Last Name:MCGRAW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 BOARDMAN DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4711
Mailing Address - Country:US
Mailing Address - Phone:505-339-2015
Mailing Address - Fax:505-492-0904
Practice Address - Street 1:816 BOARDMAN DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4711
Practice Address - Country:US
Practice Address - Phone:505-339-2015
Practice Address - Fax:505-492-0904
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM605152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ525331Medicaid
NM08778311Medicaid
NMP00841382OtherMEDICARE RAILROAD CARRIER
AZ408009Medicaid