Healthcare Provider Details

I. General information

NPI: 1083604854
Provider Name (Legal Business Name): JESS GRAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

IV. Provider business mailing address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3303
  • Fax:
Mailing address:
  • Phone: 505-272-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25061
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2018-0123
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: