Provider Demographics
NPI:1538160692
Name:GRAHAM, GARY ROBERT (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
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 1:2776 ENTERPRISE RD # 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8316
Mailing Address - Country:US
Mailing Address - Phone:386-774-1223
Mailing Address - Fax:386-774-4658
Practice Address - Street 1:2776 ENTERPRISE RD # 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8316
Practice Address - Country:US
Practice Address - Phone:386-774-1223
Practice Address - Fax:386-774-4658
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME684522085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379101700Medicaid
FL379101700Medicaid
FL27970Medicare ID - Type Unspecified