Provider Demographics
NPI:1396935912
Name:GRAVERSEN, JOSEPH A (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:A
Last Name:GRAVERSEN
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 1:209 W LANCASTER AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1749
Mailing Address - Country:US
Mailing Address - Phone:610-525-2515
Mailing Address - Fax:610-527-6586
Practice Address - Street 1:209 W LANCASTER AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1749
Practice Address - Country:US
Practice Address - Phone:610-525-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256182208800000X
CAA117518208800000X
PAMD445817208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090905Medicaid
LA1090905Medicaid