Provider Demographics
NPI:1902120553
Name:CARADONNA-GRAHAM, VIRGINIA MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:MARY
Last Name:CARADONNA-GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 HERON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0723
Mailing Address - Country:US
Mailing Address - Phone:248-310-6074
Mailing Address - Fax:
Practice Address - Street 1:1744 HERON RIDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0723
Practice Address - Country:US
Practice Address - Phone:248-338-7213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301055407207KA0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG692004Medicare UPIN