MEDICARE: AUDREY BLAIRE 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	10091T	TX
2	152W00000X	Optometrist	10091TG	TX

General Provider Information

NPI Number	:	1932711785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY BLAIRE GRAHAM OD

Provider Business Mailing Address
First Line	:	2012 WEST LOOP
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8030
Country	:	US
Telephone Number	:	979-543-6821
Fax Number	:	979-543-6817

Provider Business Practice Location Address
First Line	:	2012 WEST LOOP
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8030
Country	:	US
Telephone Number	:	979-543-6821
Fax Number	:	979-543-6817

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

Provider Enumeration Date	:	08/21/2020
Last Update Date	:	11/27/2023

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