Provider Demographics
NPI:1386751477
Name:GRAHAM, JUSTIN V (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:V
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 LARRY LN
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2707
Mailing Address - Country:US
Mailing Address - Phone:510-270-5141
Mailing Address - Fax:
Practice Address - Street 1:1860 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 300B
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3590
Practice Address - Country:US
Practice Address - Phone:707-646-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68099207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8304636Medicaid
CAH55875Medicare UPIN
CA8304636Medicaid