Provider Demographics
NPI:1205801347
Name:GRAHAM, JACK M (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
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:PO BOX 100186
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76185-0186
Mailing Address - Country:US
Mailing Address - Phone:817-731-7771
Mailing Address - Fax:817-731-7774
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1166
Practice Address - Fax:817-702-1405
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1600207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8H3360OtherBCBS
TX139366218Medicaid
TX139366223Medicaid
TX4227216OtherAETNA
TX139366219Medicaid
TX10028874OtherAMERIGROUP
TX8B2768Medicare ID - Type UnspecifiedMEDICARE
TX139366218Medicaid
TX8B2769Medicare PIN