Provider Demographics
NPI:1053517961
Name:GRAVATT, MICHAEL HOWARD II (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HOWARD
Last Name:GRAVATT
Suffix:II
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-2395
Mailing Address - Fax:
Practice Address - Street 1:620 W 1ST ST
Practice Address - Street 2:
Practice Address - City:WAPATO
Practice Address - State:WA
Practice Address - Zip Code:98951-1108
Practice Address - Country:US
Practice Address - Phone:509-877-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC071017207Q00000X
WAMD60147456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8893012Medicare PIN