Basic Information
| Provider Information | |||||||||
| NPI: | 1992818041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 331 C STREET | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253705646 | ||||||||
| FaxNumber: | 9253705142 | ||||||||
| Practice Location | |||||||||
| Address1: | 331 C ST | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945533137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253705646 | ||||||||
| FaxNumber: | 9253705142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 05/19/2016 | ||||||||
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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 | 207R00000X | G35252 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G352520 | 01 | CA | MEDI-CAL | OTHER |