Provider Demographics
NPI:1780684571
Name:ABRAMS, JACK EBRAHIMPOUR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:EBRAHIMPOUR
Last Name:ABRAMS
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 1:4800 N 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4963
Mailing Address - Country:US
Mailing Address - Phone:702-304-9494
Mailing Address - Fax:702-304-9495
Practice Address - Street 1:6450 MEDICAL CENTER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-2442
Practice Address - Country:US
Practice Address - Phone:702-304-9494
Practice Address - Fax:702-304-9495
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2022-05-24
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
NV9777207W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018382Medicaid
NV40622Medicare ID - Type Unspecified
NV002018382Medicaid