Provider Demographics
NPI:1104137447
Name:GRAHAM, NICHOLAS D (OD, MS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:D
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2085
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28106-2085
Mailing Address - Country:US
Mailing Address - Phone:843-245-0427
Mailing Address - Fax:
Practice Address - Street 1:855 SAM NEWELL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-7593
Practice Address - Country:US
Practice Address - Phone:843-245-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1599152W00000X
NC2222152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA52778014Medicare UPIN