Provider Demographics
NPI:1720042864
Name:ABRAHAM, REGINALD G M (M D)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:G M
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11100 WARNER AVE
Mailing Address - Street 2:SUITE 258
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7506
Mailing Address - Country:US
Mailing Address - Phone:714-549-5990
Mailing Address - Fax:714-845-0041
Practice Address - Street 1:11100 WARNER AVE
Practice Address - Street 2:SUITE 258
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7506
Practice Address - Country:US
Practice Address - Phone:714-549-5990
Practice Address - Fax:714-549-0866
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75917174400000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A75917Medicaid
CA00A75917Medicaid