MEDICARE: DR. CHARLES E GRAHAM M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	C31279	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C31279	OTHER	CA	STATE LICENSE
2	1962487728	OTHER	CA	NATIONAL PROVIDER INDENTIFIER

General Provider Information

NPI Number	:	1962487728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES E GRAHAM M.D.

Provider Business Mailing Address
First Line	:	6037 LA GRANADA #1223
Second Line	:
City	:	RANCHO SANTA FE
State	:	CA
Zip	:	92067-1223
Country	:	US
Telephone Number	:	858-756-5475
Fax Number	:	858-756-7639

Provider Business Practice Location Address
First Line	:	6037 LA GRANADA PMB 1223
Second Line	:	PMB 1223
City	:	RANCHO SANTA FE
State	:	CA
Zip	:	92067-1223
Country	:	US
Telephone Number	:	858-756-5475
Fax Number	:	858-756-7639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	03/07/2023

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