=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922535830
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEMAAR GRAHAM DPM PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2017
-----------------------------------------------------
Last Update Date | 05/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12839 GRAND BANK LN
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-398-6309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12839 GRAND BANK LN
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICIER
-----------------------------------------------------
Name | DR. JEMAAR LEKEI GRAHAM
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 863-398-6309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number | PO3096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------