Provider Demographics
NPI:1881773703
Name:GRAHAM, TREVA JO (MD)
Entity type:Individual
Prefix:MRS
First Name:TREVA
Middle Name:JO
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 NE HIGHWAY 66
Mailing Address - Street 2:STE 2
Mailing Address - City:SAYRE
Mailing Address - State:OK
Mailing Address - Zip Code:73662-9305
Mailing Address - Country:US
Mailing Address - Phone:580-928-2208
Mailing Address - Fax:580-928-2246
Practice Address - Street 1:1002 NE HIGHWAY 66
Practice Address - Street 2:STE 2
Practice Address - City:SAYRE
Practice Address - State:OK
Practice Address - Zip Code:73662-9305
Practice Address - Country:US
Practice Address - Phone:580-928-2208
Practice Address - Fax:580-928-2246
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100117500BMedicaid
OK248228503Medicare ID - Type Unspecified
OKH68472Medicare UPIN