Provider Demographics
NPI:1902880529
Name:GRAHAM, WALTER E (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:E
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 NORTH PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339
Mailing Address - Country:US
Mailing Address - Phone:281-359-5330
Mailing Address - Fax:281-359-6117
Practice Address - Street 1:1331 NORTH PARK DRIVE
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339
Practice Address - Country:US
Practice Address - Phone:281-359-5330
Practice Address - Fax:281-359-6117
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15564R207L00000X
TXH4357207L00000X, 207P00000X, 207Q00000X
CO29172207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1468037Medicaid
LA4J362Medicare ID - Type Unspecified
TX00515LMedicare PIN
TXPH0533Medicare PIN
E02227Medicare UPIN