MEDICARE: GARY ROBERT GRAHAM 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	2085R0001X	Radiation Oncology Physician	ME68452	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	:	1538160692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY ROBERT GRAHAM M.D.

Provider Business Mailing Address
First Line	:	2776 ENTERPRISE RD # 100
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8316
Country	:	US
Telephone Number	:	386-774-1223
Fax Number	:	386-774-4658

Provider Business Practice Location Address
First Line	:	2776 ENTERPRISE RD # 100
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8316
Country	:	US
Telephone Number	:	386-774-1223
Fax Number	:	386-774-4658

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	12/13/2017

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