Basic Information
| Provider Information | |||||||||
| NPI: | 1528716297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | SAN ANTONIO MILITARY MEDICAL CENTER, MCHE-ZDM, INTERNAL | ||||||||
| Address2: | 3551 ROGER BROOKE DR. | ||||||||
| City: | JBSA-FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102927805 | ||||||||
| FaxNumber: | 2102927868 | ||||||||
| Practice Location | |||||||||
| Address1: | SAN ANTONIO MILITARY MEDICAL CENTER, MCHE-ZDM, INTERNAL | ||||||||
| Address2: | 3551 ROGER BROOKE DR. | ||||||||
| City: | JBSA-FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782344504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102927805 | ||||||||
| FaxNumber: | 2102927868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2022 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/12/2022 | ||||||||
| NPIReactivationDate: | 03/28/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.