Provider Demographics
NPI:1023168481
Name:GRAVES, TERRY S (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:S
Last Name:GRAVES
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 1:8104 BROOKSIDE PL
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 N MAYFAIR RD
Practice Address - Street 2:SUITE 220
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1409
Practice Address - Country:US
Practice Address - Phone:414-475-9101
Practice Address - Fax:414-475-9203
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30249900Medicaid
WIB53202Medicare UPIN
WI1457Medicare ID - Type Unspecified