Provider Demographics
NPI:1770581662
Name:GRAVENOR, DONALD ST PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ST PAUL
Last Name:GRAVENOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:6029 WALNUT GROVE RD
Practice Address - Street 2:SUITE #301
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-747-9081
Practice Address - Fax:901-747-9087
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS17589207RH0003X
ARE-3381207RH0003X
TN30833207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3859276Medicaid
TN3859276Medicaid
TN3859276Medicaid