Healthcare Provider Details

I. General information

NPI: 1801868112
Provider Name (Legal Business Name): STEPHEN L GRAHAM M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 3RD ST STE# 485W
LOS ANGELES CA
90048-6101
US

IV. Provider business mailing address

8635 W 3RD ST STE# 485W
LOS ANGELES CA
90048-6101
US

V. Phone/Fax

Practice location:
  • Phone: 310-652-9160
  • Fax:
Mailing address:
  • Phone: 310-652-9160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberG33123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: