Basic Information
| Provider Information | |||||||||
| NPI: | 1467486951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | WILLIAM | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42510 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972420510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039631290 | ||||||||
| FaxNumber: | 5032301541 | ||||||||
| Practice Location | |||||||||
| Address1: | 2804 SE STEELE ST # 2 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972024525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032322163 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208600000X | DO07543 | OR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8107633 | 01 | DSHS | OTHER |