Provider Demographics
NPI:1356030993
Name:GRAHAM, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:HOLDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 207170
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7170
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:6828 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-3050
Practice Address - Country:US
Practice Address - Phone:502-231-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY2349DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program