Basic Information
| Provider Information | |||||||||
| NPI: | 1386751477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 LARRY LN | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946112707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102705141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1860 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 300B | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945333590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076464180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | A68099 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 8304636 | 05 | CA | MEDICAID |