Healthcare Provider Details

I. General information

NPI: 1437269081
Provider Name (Legal Business Name): JOHN DAVID GRAHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N BALLAS RD STE C-11
SAINT LOUIS MO
63131-2321
US

IV. Provider business mailing address

PO BOX 953010
ST LOUIS MO
63195-3010
US

V. Phone/Fax

Practice location:
  • Phone: 314-872-5601
  • Fax: 314-872-5628
Mailing address:
  • Phone: 314-872-5601
  • Fax: 314-872-5628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number109904
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number036092540
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: