Basic Information
| Provider Information | |||||||||
| NPI: | 1962606822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | BENNET | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NE NEFF RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9125 CROSS PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656325900 | ||||||||
| FaxNumber: | 8653742129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N1655 | TX | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | N1655 | TX | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | MD197688 | OR | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | Q068060 | 05 | TN | MEDICAID |