MEDICARE: DR. NICHOLAS D GRAHAM O.D., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1599	SC
2	152W00000X	Optometrist	2222	NC

General Provider Information

NPI Number	:	1104137447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS D GRAHAM O.D., M.S.

Provider Business Mailing Address
First Line	:	PO BOX 2085
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28106-2085
Country	:	US
Telephone Number	:	843-245-0427
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 SAM NEWELL RD
Second Line	:	SUITE 203
City	:	MATTHEWS
State	:	NC
Zip	:	28105-7593
Country	:	US
Telephone Number	:	843-245-0427
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	11/14/2012

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