MEDICARE: DR. ROBERT JACKSON GRAHAM OD

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	0008729T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	770541071	OTHER	CA	VISION SERVICE PLAN
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	6567	OTHER	CA	MEDICAL EYE SERVICES

General Provider Information

NPI Number	:	1750365052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT JACKSON GRAHAM OD

Provider Business Mailing Address
First Line	:	PO BOX 880
Second Line	:
City	:	OJAI
State	:	CA
Zip	:	93024-0880
Country	:	US
Telephone Number	:	805-646-8510
Fax Number	:	805-646-2968

Provider Business Practice Location Address
First Line	:	635 E OJAI AVE
Second Line	:
City	:	OJAI
State	:	CA
Zip	:	93023-2822
Country	:	US
Telephone Number	:	805-646-8510
Fax Number	:	805-646-2968

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

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	08/21/2012

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