Provider Demographics
NPI:1376665794
Name:GRAHAM, BRIAN HILTON (MD,)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:HILTON
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6455 LA JOLLA BLVD, 315
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-6638
Mailing Address - Country:US
Mailing Address - Phone:619-665-2159
Mailing Address - Fax:858-836-1159
Practice Address - Street 1:6455 LA JOLLA BLVD UNIT 315
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-6638
Practice Address - Country:US
Practice Address - Phone:619-665-2159
Practice Address - Fax:858-836-1159
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-05
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67969207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE90629Medicare UPIN