Provider Demographics
NPI:1962487728
Name:GRAHAM, CHARLES E (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6037 LA GRANADA #1223
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-1223
Mailing Address - Country:US
Mailing Address - Phone:858-756-5475
Mailing Address - Fax:858-756-7639
Practice Address - Street 1:6037 LA GRANADA PMB 1223
Practice Address - Street 2:PMB 1223
Practice Address - City:RANCHO SANTA FE
Practice Address - State:CA
Practice Address - Zip Code:92067-1223
Practice Address - Country:US
Practice Address - Phone:858-756-5475
Practice Address - Fax:858-756-7639
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC31279OtherSTATE LICENSE
CA1962487728OtherNATIONAL PROVIDER INDENTIFIER
CAAG4387052OtherDEA
CAAG4387052OtherDEA