Provider Demographics
NPI:1609004118
Name:ABRAHAM, MARK (DOM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11025 POND PINE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-2235
Mailing Address - Country:US
Mailing Address - Phone:813-732-2108
Mailing Address - Fax:
Practice Address - Street 1:11025 POND PINE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-2235
Practice Address - Country:US
Practice Address - Phone:813-732-2108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 2707171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist