Healthcare Provider Details

I. General information

NPI: 1205079506
Provider Name (Legal Business Name): ANDRE T GRAVES D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY STREET
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

PO BOX 2400
MELBOURNE FL
32902-2400
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7000
  • Fax:
Mailing address:
  • Phone: 321-837-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS13147
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: