Provider Demographics
NPI:1962025486
Name:GRAHAM, ELLIS MARTINEZ JR
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:MARTINEZ
Last Name:GRAHAM
Suffix:JR
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 1:24695 MAPLE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-1274
Mailing Address - Country:US
Mailing Address - Phone:216-278-5702
Mailing Address - Fax:
Practice Address - Street 1:24695 MAPLE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-1274
Practice Address - Country:US
Practice Address - Phone:216-278-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist