Provider Demographics
NPI:1861581084
Name:GRAVES, SUSAN E (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:WILT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3203 E OLD STONE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MO
Practice Address - Zip Code:65619
Practice Address - Country:US
Practice Address - Phone:417-269-1910
Practice Address - Fax:417-269-1916
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO105796OtherBCMO
MO105796OtherBCMO
G43728Medicare UPIN
129050038Medicare PIN