Provider Demographics
NPI:1760441828
Name:ABRAHAM, FRED D (OD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:D
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 11TH AVE S STE 14
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5263
Mailing Address - Country:US
Mailing Address - Phone:406-455-2020
Mailing Address - Fax:
Practice Address - Street 1:2800 11TH AVE S STE 14
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5263
Practice Address - Country:US
Practice Address - Phone:406-455-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT834152W00000X
OH4435 T1159152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0932003Medicaid
OH0932003Medicaid
U45158Medicare UPIN
0670590001Medicare NSC