Healthcare Provider Details

I. General information

NPI: 1083008460
Provider Name (Legal Business Name): DANIEL GRAHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SHREWSBURY PLZ
SHREWSBURY NJ
07702-4322
US

IV. Provider business mailing address

PO BOX 8519
RED BANK NJ
07701-8519
US

V. Phone/Fax

Practice location:
  • Phone: 732-542-0002
  • Fax: 732-542-2992
Mailing address:
  • Phone: 732-460-9840
  • Fax: 732-460-9848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB10197200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: