Provider Demographics
NPI:1316109317
Name:GRAHAM, COREY FRENCH (MD)
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:FRENCH
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7916 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-434-6071
Mailing Address - Fax:260-434-6389
Practice Address - Street 1:1000 PROVIDENT DR
Practice Address - Street 2:SUITE C
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3255
Practice Address - Country:US
Practice Address - Phone:574-267-8728
Practice Address - Fax:574-269-3470
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074316A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN262490014OtherMEDICARE PTAN
IN201246970Medicaid