Provider Demographics
NPI:1831440593
Name:GRAHAM, DONALD GENE (RT(R))
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:GENE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:GENE
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RT(R)
Mailing Address - Street 1:2751 WOODLAKE RD SW APT 2
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4653
Mailing Address - Country:US
Mailing Address - Phone:616-667-7138
Mailing Address - Fax:
Practice Address - Street 1:2751 WOODLAKE RD SW APT 2
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4653
Practice Address - Country:US
Practice Address - Phone:616-667-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI341390247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist