Provider Demographics
NPI:1275677965
Name:GRAHAM, EMMANUEL S (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:S
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:PO BOX 6883
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00823-6883
Mailing Address - Country:US
Mailing Address - Phone:340-719-8761
Mailing Address - Fax:340-719-8764
Practice Address - Street 1:4F-5F SUNNY ISLES PROFESSIONAL BUILDING
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820
Practice Address - Country:US
Practice Address - Phone:340-719-8761
Practice Address - Fax:340-719-8764
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VI1455208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI002-8793OtherMEDICARE PTAN