Healthcare Provider Details

I. General information

NPI: 1841579471
Provider Name (Legal Business Name): DONALD CLIFFORD GRAVES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2011
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 W US HIGHWAY 30
SCHERERVILLE IN
46375-1562
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-703-2440
  • Fax: 219-703-6759
Mailing address:
  • Phone: 219-392-7084
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005604
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number07001368A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: