Provider Demographics
NPI:1548730997
Name:ANDRE GRAHAM MD PLLC
Entity type:Organization
Organization Name:ANDRE GRAHAM MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-351-6830
Mailing Address - Street 1:7777 FOREST LN STE C670
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-6804
Mailing Address - Country:US
Mailing Address - Phone:972-789-5539
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN STE C670
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-6804
Practice Address - Country:US
Practice Address - Phone:972-789-5539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185966202Medicaid