Healthcare Provider Details

I. General information

NPI: 1588105811
Provider Name (Legal Business Name): MICKEY GRAPHIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8888 SUMMA AVE
BATON ROUGE LA
70809-3772
US

IV. Provider business mailing address

8888 SUMMA AVE
BATON ROUGE LA
70809-3772
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-4493
  • Fax:
Mailing address:
  • Phone: 225-769-4493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number125.072356
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number338178
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: