Healthcare Provider Details

I. General information

NPI: 1801917596
Provider Name (Legal Business Name): PAUL WILLIAM GRAVES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 S 2ND ST
GALLUP NM
87301-5813
US

IV. Provider business mailing address

1300 S 2ND ST
GALLUP NM
87301-5813
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-3388
  • Fax: 505-722-3530
Mailing address:
  • Phone: 505-722-3388
  • Fax: 505-722-3530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number354
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: