Basic Information
| Provider Information | |||||||||
| NPI: | 1437359056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 SOUTHPOINT PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Practice Location | |||||||||
| Address1: | 4565 US HIGHWAY 17 STE 200 | ||||||||
| Address2: | |||||||||
| City: | FLEMING ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320034823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2007 | ||||||||
| LastUpdateDate: | 08/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | OT012086 | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 0536176 | KS | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 5312 | OK | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 2013009584 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | OS11534 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | AETNA | OTHER | PENDING | 01 | FL | BCBS | OTHER | 14KA4 | 01 | FL | BCBS | OTHER | 004857900 | 05 | FL | MEDICAID | PENDING | 01 | FL | CIGNA | OTHER |