Healthcare Provider Details

I. General information

NPI: 1962487728
Provider Name (Legal Business Name): CHARLES E GRAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6037 LA GRANADA PMB 1223 PMB 1223
RANCHO SANTA FE CA
92067-1223
US

IV. Provider business mailing address

6037 LA GRANADA #1223
RANCHO SANTA FE CA
92067-1223
US

V. Phone/Fax

Practice location:
  • Phone: 858-756-5475
  • Fax: 858-756-7639
Mailing address:
  • Phone: 858-756-5475
  • Fax: 858-756-7639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC31279
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: