Provider Demographics
NPI:1023090503
Name:GRAHAM, LARRY C II (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:C
Last Name:GRAHAM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:13715 PINNACLE DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67230-1545
Mailing Address - Country:US
Mailing Address - Phone:316-733-2307
Mailing Address - Fax:
Practice Address - Street 1:3600 E HARRY ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-3713
Practice Address - Country:US
Practice Address - Phone:316-689-5050
Practice Address - Fax:316-689-6192
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS04-287632085R0204X, 2085U0001X, 2085B0100X, 2085N0904X, 2085N0700X, 2085P0229X, 2085R0202X, 2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100420330CMedicaid
OK100173090AMedicaid
MO1023090503Medicaid
KS300132252OtherRR MEDICARE
MO1023090503Medicaid
KS100420330CMedicaid