1619314978 NPI number — JERI D. GRAHAM O.D.,P.A.

Table of content: (NPI 1619314978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619314978 NPI number — JERI D. GRAHAM O.D.,P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERI D. GRAHAM O.D.,P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619314978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1239 SR 436
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CASSELBERRY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32707-2707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-263-3937
Provider Business Mailing Address Fax Number:
407-671-9656

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1239 SR 436
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CASSELBERRY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32707-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-263-3937
Provider Business Practice Location Address Fax Number:
407-671-9656
Provider Enumeration Date:
05/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
JERI
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-263-3937

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC2446 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 078790600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1851328496 . This is a "INDIIDUAL NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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