Provider Demographics
NPI:1932711785
Name:GRAHAM, AUDREY BLAIRE (OD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:BLAIRE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:BLAIRE
Other - Last Name:KORENEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2012 WEST LOOP
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-8030
Mailing Address - Country:US
Mailing Address - Phone:979-543-6821
Mailing Address - Fax:979-543-6817
Practice Address - Street 1:2012 WEST LOOP
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-8030
Practice Address - Country:US
Practice Address - Phone:979-543-6821
Practice Address - Fax:979-543-6817
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10091T152W00000X
TX10091TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist