Individual
JACK M GRAHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1500 S MAIN ST, FORT WORTH, TX 76104-4917
(817) 702-1166
(817) 702-1405
Mailing address
PO BOX 100186, FORT WORTH, TX 76185-0186
(817) 731-7771
(817) 731-7774
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
F1600
TX
207VM0101X
Maternal & Fetal Medicine Physician
Primary
F1600
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10028874
AMERIGROUP
TX
05
—
139366218
—
TX
05
—
139366219
—
TX
05
—
139366223
—
TX
01
—
4227216
AETNA
TX
01
—
8H3360
BCBS
TX
Enumeration date
02/22/2006
Last updated
12/28/2021
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