Provider Demographics
NPI:1649319237
Name:GRAHAM, VICKY (OD)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-4806
Mailing Address - Country:US
Mailing Address - Phone:303-939-8021
Mailing Address - Fax:
Practice Address - Street 1:1230 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-4806
Practice Address - Country:US
Practice Address - Phone:303-939-8021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1475152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
COF1543Medicare ID - Type Unspecified
COU43505Medicare UPIN