Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0400X | Neurologist | G21341 | CA |
NPI | 1033134564 |
---|---|
Provider Name | Michael Clark Graves |
First Address | Los Angeles, CA 90045-5631 |
Second Address | Los Angeles, CA 90095-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/07/2006 |
Last Update Date | 28/09/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G213410 | (05) | CA |
A90700 | (02) | CA |