Provider Demographics
NPI:1285924837
Name:GRAHAM DERMATOLOGY CENTER, P.C.
Entity type:Organization
Organization Name:GRAHAM DERMATOLOGY CENTER, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-216-0100
Mailing Address - Street 1:307 E DANFORTH RD
Mailing Address - Street 2:SUITE 154
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-4483
Mailing Address - Country:US
Mailing Address - Phone:405-216-0100
Mailing Address - Fax:
Practice Address - Street 1:307 E DANFORTH RD
Practice Address - Street 2:SUITE 154
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4483
Practice Address - Country:US
Practice Address - Phone:405-216-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-17
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20601207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1912902842OtherNPI