Provider Demographics
NPI:1457741076
Name:GRAHAM MOUW, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GRAHAM MOUW, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MAE
Authorized Official - Middle Name:
Authorized Official - Last Name:VARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-895-2126
Mailing Address - Street 1:5525 ETIWANDA AVE
Mailing Address - Street 2:SUITE 324
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3647
Mailing Address - Country:US
Mailing Address - Phone:818-895-2126
Mailing Address - Fax:818-304-7546
Practice Address - Street 1:5525 ETIWANDA AVE
Practice Address - Street 2:SUITE 324
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3647
Practice Address - Country:US
Practice Address - Phone:818-895-2126
Practice Address - Fax:818-304-7546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78281207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty