Basic Information
| Provider Information | |||||||||
| NPI: | 1780635987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAFF | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063602737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604258715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 88 NORWICH NEW LONDON TPKE | ||||||||
| Address2: | |||||||||
| City: | UNCASVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063822518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608481297 | ||||||||
| FaxNumber: | 8608489875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 05/07/2010 | ||||||||
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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 | 207Q00000X | 5315012642 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4622613 | 01 | CT | AETNA | OTHER |