Healthcare Provider Details

I. General information

NPI: 1205831666
Provider Name (Legal Business Name): BOBBY L GRAHAM JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-5900
  • Fax: 601-200-5959
Mailing address:
  • Phone: 601-200-5900
  • Fax: 225-765-5727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number10277
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number10277
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: