Provider Demographics
NPI:1831278589
Name:GRAHAM, TRACY WARWICK (MD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:WARWICK
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MICHELLE
Other - Last Name:WARWICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:706 MAIN ST STE 2A
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6010
Practice Address - Country:US
Practice Address - Phone:541-851-7350
Practice Address - Fax:541-851-7351
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23546208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286410Medicaid
CAXPY197937Medicaid
OR286410Medicaid