Provider Demographics
NPI:1952318552
Name:GRAHAM, ANGUS W (MD)
Entity Type:Individual
Prefix:MR
First Name:ANGUS
Middle Name:W
Last Name:GRAHAM
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 1:300 RIVERSIDE DR E
Mailing Address - Street 2:STE 4300
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208
Mailing Address - Country:US
Mailing Address - Phone:941-747-3034
Mailing Address - Fax:941-748-5819
Practice Address - Street 1:300 RIVERSIDE DR E
Practice Address - Street 2:STE 4300
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:941-747-3034
Practice Address - Fax:941-748-5819
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH1112YMedicare ID - Type Unspecified
D62394Medicare UPIN