Provider Demographics
NPI:1497851166
Name:GRAHAM, JACKIE LYNN IV (MD)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:LYNN
Last Name:GRAHAM
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:L
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1600 SE MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5423
Mailing Address - Country:US
Mailing Address - Phone:505-623-8100
Mailing Address - Fax:505-623-8101
Practice Address - Street 1:1600 SE MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5423
Practice Address - Country:US
Practice Address - Phone:505-623-8100
Practice Address - Fax:505-623-8101
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74-39207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11023Medicaid
NM11023Medicaid
NMD35666Medicare UPIN