Provider Demographics
NPI:1891702148
Name:GRAVES, MATTHEW L (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:GRAVES
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6525
Mailing Address - Fax:601-815-1722
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6525
Practice Address - Fax:601-815-1722
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18139174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL156441Medicaid
MS1891702148OtherNPI
MS512G700003OtherUP MEDICARE
LA1335061Medicaid
AL106655Medicaid
MS512I200002OtherMEDICARE PTAN
MSP00643807OtherUP RRMCR PTAN
MS01301804Medicaid
MS18139OtherMEDICAL LICENSE
MS200000517OtherMEDICARE
MS18139OtherMEDICAL LICENSE
MS512I200002OtherMEDICARE PTAN
AL106655Medicaid