Provider Demographics
NPI:1235118811
Name:ABRAHIM, KEN SI (MD)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:SI
Last Name:ABRAHIM
Suffix:
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 1:1125 TOWN PARK AVE
Mailing Address - Street 2:SUITE 1125
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4791
Mailing Address - Country:US
Mailing Address - Phone:407-804-9494
Mailing Address - Fax:407-804-9443
Practice Address - Street 1:1125 TOWN PARK AVE
Practice Address - Street 2:SUITE 1125
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-4791
Practice Address - Country:US
Practice Address - Phone:407-804-9494
Practice Address - Fax:407-804-9443
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I43047Medicare UPIN
FLU6098Medicare ID - Type Unspecified