Jackie Lynn Graham IV, M.D.

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

74-39 Issued in NM

Practice address

1600 SE Main St Ste E
Roswell, NM 88203-5423

Phone

(505) 623-8100

Fax

(505) 623-8101

NPI assigned

Sep 16, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Dr. Jack L Graham Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158364800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1215475200000",
    "number": "1497851166",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1600 SE MAIN ST STE E",
            "city": "ROSWELL",
            "state": "NM",
            "postal_code": "882035423",
            "telephone_number": "505-623-8100",
            "fax_number": "505-623-8101"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 SE MAIN ST STE E",
            "city": "ROSWELL",
            "state": "NM",
            "postal_code": "882035423",
            "telephone_number": "505-623-8100",
            "fax_number": "505-623-8101"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GRAHAM",
        "first_name": "JACKIE",
        "middle_name": "LYNN",
        "name_prefix": "Dr.",
        "name_suffix": "IV",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-16",
        "last_updated": "2008-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": "NM",
            "license": "74-39",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11023",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "JACK",
            "last_name": "GRAHAM",
            "middle_name": "L",
            "prefix": "DR.",
            "credential": "M.D.",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Mikaela Gonzalez
• Angel R Gordo, LSAA
• Seth Gordon, PT
• Matthew Ryan Gorman, PA-C
• Lori Ann Gossett, DDS, MS
• Anna Grajeda, MSW
• Jessica Granado
• Eloise E Granados, LPN
• Fatima A Granados, LMSW
• Camille Cleo Gray, MS CCC-SLP

• Dermatology Physician in Roswell, NM
• Providers in Roswell, NM by specialty
• Dermatology Physician in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.