Healthcare Provider Details

I. General information

NPI: 1477567170
Provider Name (Legal Business Name): GARY R GRAHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 BELFORD CIR
BROOMFIELD CO
80023-8110
US

IV. Provider business mailing address

4605 BELFORD CIR
BROOMFIELD CO
80023-8110
US

V. Phone/Fax

Practice location:
  • Phone: 720-234-2682
  • Fax:
Mailing address:
  • Phone: 720-234-2682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberC 51164
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number39362
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: