Organization
JACK L GRAHAM, MD, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACK LYNN GRAHAM M.D. (OWNER)
(505) 623-8100
Entity
Organization
Contact information
Practice address
1600 SE MAIN ST STE E, ROSWELL, NM 88203-5423
(505) 623-8100
(505) 623-8101
Mailing address
1600 SE MAIN ST STE E, ROSWELL, NM 88203-5423
(505) 623-8100
(505) 623-8101
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
74-39
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
11023
—
NM
Enumeration date
09/16/2006
Last updated
07/11/2008
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