Provider Demographics
NPI:1518921642
Name:GRAHAM, MARLON ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:MARLON
Middle Name:ANTHONY
Last Name:GRAHAM
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:512 VILLAGE RD STE 104
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3409
Practice Address - Country:US
Practice Address - Phone:910-721-4200
Practice Address - Fax:910-754-3811
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010395372084P0800X
NC2024-025002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA179154OtherANTHEM
VA179156OtherANTHEM
VA178300OtherANTHEM
VA01455137OtherAMERIGROUP
VA552451OtherVALUE OPTIONS
VA004945298Medicaid
VA179154OtherANTHEM
VA178300OtherANTHEM
009113M23Medicare PIN
007193M13Medicare PIN
009756M94Medicare PIN
VA004945298Medicaid