Provider Demographics
NPI:1780680363
Name:GRAHAM, JOHN MAITLAND (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MAITLAND
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 LINCOLN WAY E
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46561-2767
Mailing Address - Country:US
Mailing Address - Phone:574-674-6700
Mailing Address - Fax:574-674-7171
Practice Address - Street 1:320 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:IN
Practice Address - Zip Code:46561-2767
Practice Address - Country:US
Practice Address - Phone:574-674-6700
Practice Address - Fax:574-674-7171
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001454A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000093107OtherANTHEM
INRR MEDICAREOther200034182
IN200187380BMedicaid
IN184910Medicare PIN
INF62435Medicare UPIN
IN200187380BMedicaid