Provider Demographics
NPI:1518388099
Name:ABRAHAM, NICHOLAS ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ETHAN
Last Name:ABRAHAM
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 1:1300 W 9TH ST
Mailing Address - Street 2:APT 347
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-1031
Mailing Address - Country:US
Mailing Address - Phone:617-717-8557
Mailing Address - Fax:
Practice Address - Street 1:1300 W 9TH ST
Practice Address - Street 2:APT 347
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-1031
Practice Address - Country:US
Practice Address - Phone:617-717-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.122563207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019062000Medicaid