Provider Demographics
NPI:1346284668
Name:ABRAHAM OWUSU DOMMEY LLC
Entity Type:Organization
Organization Name:ABRAHAM OWUSU DOMMEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:OWUSU DOMMEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-821-9339
Mailing Address - Street 1:PO BOX 2510
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85214-2510
Mailing Address - Country:US
Mailing Address - Phone:480-821-9339
Mailing Address - Fax:480-821-9555
Practice Address - Street 1:3303 S LINDSAY RD
Practice Address - Street 2:STE 123
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-1503
Practice Address - Country:US
Practice Address - Phone:480-821-9339
Practice Address - Fax:480-821-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ26852174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ491176Medicaid
AZ491176Medicaid
AZZ111835Medicare PIN
AZZ111834Medicare PIN