Provider Demographics
NPI:1912902842
Name:GRAHAM, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
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 1:307 E DANFORTH AVE
Mailing Address - Street 2:SUITE 154
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-4487
Mailing Address - Country:US
Mailing Address - Phone:405-216-0100
Mailing Address - Fax:
Practice Address - Street 1:307 E DANFORTH RD
Practice Address - Street 2:SUITE 154
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4483
Practice Address - Country:US
Practice Address - Phone:405-216-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20601174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1912902842OtherNPI
OK942771257-001OtherBLUE CROSS
OK070016120OtherRAILROAD MEDICARE
OK1912902842OtherNPI
OK942771257-001OtherBLUE CROSS