Provider Demographics
NPI:1194700021
Name:GRAVES, WHITE SOLOMON IV (MD)
Entity type:Individual
Prefix:DR
First Name:WHITE
Middle Name:SOLOMON
Last Name:GRAVES
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1501 LOUISVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6025
Mailing Address - Country:US
Mailing Address - Phone:318-323-8451
Mailing Address - Fax:318-361-2613
Practice Address - Street 1:1501 LOUISVILLE AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6025
Practice Address - Country:US
Practice Address - Phone:318-323-8451
Practice Address - Fax:318-361-2613
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA14205R207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1107131Medicaid
LA1107131Medicaid
H21975Medicare UPIN