Provider Demographics
NPI:1083667703
Name:ABRAHAM, ANES WILEY (MD)
Entity Type:Individual
Prefix:MS
First Name:ANES
Middle Name:WILEY
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 NORTH 10TH ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315
Mailing Address - Country:US
Mailing Address - Phone:870-763-1700
Mailing Address - Fax:870-763-2903
Practice Address - Street 1:1521 NORTH 10TH ST
Practice Address - Street 2:SUITE H
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315
Practice Address - Country:US
Practice Address - Phone:870-763-1700
Practice Address - Fax:870-763-2903
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR3291208000000X
TXG4512208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D83871Medicare UPIN