Provider Demographics
NPI:1386756070
Name:GRABER, CHARLES JACOB (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JACOB
Last Name:GRABER
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 1:215 S PINE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-3543
Mailing Address - Country:US
Mailing Address - Phone:316-283-0033
Mailing Address - Fax:
Practice Address - Street 1:215 S PINE
Practice Address - Street 2:#303
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-3543
Practice Address - Country:US
Practice Address - Phone:316-283-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS417578208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100825Medicaid
000843Medicare ID - Type Unspecified
KS100825Medicaid