Provider Demographics
NPI:1912975434
Name:GRAVES, RICHARD HENRY III (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:HENRY
Last Name:GRAVES
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3848
Mailing Address - Country:US
Mailing Address - Phone:562-433-0478
Mailing Address - Fax:562-438-3690
Practice Address - Street 1:304 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-3848
Practice Address - Country:US
Practice Address - Phone:562-433-0478
Practice Address - Fax:562-438-3690
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3954213ES0000X, 213E00000X
CAE-3954213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU50873Medicare UPIN