Healthcare Provider Details

I. General information

NPI: 1285924837
Provider Name (Legal Business Name): GRAHAM DERMATOLOGY CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2011
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E DANFORTH RD SUITE 154
EDMOND OK
73034-4483
US

IV. Provider business mailing address

307 E DANFORTH RD SUITE 154
EDMOND OK
73034-4483
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-0100
  • Fax:
Mailing address:
  • Phone: 405-216-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number20601
License Number StateOK

VIII. Authorized Official

Name: DR. DAVID L GRAHAM
Title or Position: OWNER
Credential: M.D.
Phone: 405-216-0100