MEDICARE: MRS. VERONICA A KON GRAVERSEN M.D.

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	207W00000X	Ophthalmology Physician	ME139314	FL
2	207WX0108X	Uveitis and Ocular Inflammatory Disease (Ophthalmology) Physician	ME139313	FL
3	207WX0107X	Retina Specialist (Ophthalmology) Physician	ME139314	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467773838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VERONICA A KON GRAVERSEN M.D.

Provider Business Mailing Address
First Line	:	1567 HAYLEY LN STE 101
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2109
Country	:	US
Telephone Number	:	239-337-3337
Fax Number	:	239-936-6984

Provider Business Practice Location Address
First Line	:	1567 HAYLEY LN STE 101
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2109
Country	:	US
Telephone Number	:	239-337-3337
Fax Number	:	239-936-6984

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

Provider Enumeration Date	:	06/18/2010
Last Update Date	:	08/10/2021

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