1356483861 NPI number — DR. DRAYTON P GRAHAM MD

Table of content: DR. DRAYTON P GRAHAM MD (NPI 1356483861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356483861 NPI number — DR. DRAYTON P GRAHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
DRAYTON
Provider Middle Name:
P
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAHAM
Provider Other First Name:
DRAYTON
Provider Other Middle Name:
P.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DRAYTON P. GRAHAMMD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1356483861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4477 W 118TH ST STE 405
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAWTHORNE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90250-2259
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-970-1930
Provider Business Mailing Address Fax Number:
310-970-1979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4477 W 118TH ST STE 405
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAWTHORNE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90250-2259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-970-1930
Provider Business Practice Location Address Fax Number:
928-268-0107
Provider Enumeration Date:
02/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  G27833 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 953385758 . This is a "DRAYTON P. GRAHAM M.D. MEDICAL INC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G278330 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".