Provider Demographics
NPI:1912561721
Name:MITRO, GRAHAM BENSON
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:BENSON
Last Name:MITRO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 MEDICAL CENTER DR STE 3930
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-0028
Mailing Address - Country:US
Mailing Address - Phone:615-936-0060
Mailing Address - Fax:
Practice Address - Street 1:1301 MEDICAL CENTER DR STE 3930
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-936-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-26
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN653032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program