Provider Demographics
NPI:1932312097
Name:GRAHAM, SCOTT DAVID (HM IDC)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:HM IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:EODMU 5 UNIT 25499
Mailing Address - Street 2:2112 SUMAY COVE DRIVE
Mailing Address - City:SANTA RITA
Mailing Address - State:GUAM
Mailing Address - Zip Code:96915
Mailing Address - Country:UM
Mailing Address - Phone:671-339-8171
Mailing Address - Fax:671-339-8179
Practice Address - Street 1:EODMU 5 UNIT 25499
Practice Address - Street 2:2112 SUMAY COVE DRIVE
Practice Address - City:SANTA RITA
Practice Address - State:GAUM
Practice Address - Zip Code:96915
Practice Address - Country:UM
Practice Address - Phone:671-339-8171
Practice Address - Fax:671-339-8179
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman