Provider Demographics
NPI:1891198149
Name:ABRAHAM, DESALEGN
Entity Type:Individual
Prefix:
First Name:DESALEGN
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418056
Mailing Address - Street 2:DOCTORS COMMUNITY MEDICAL GROUP LLC
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-8056
Mailing Address - Country:US
Mailing Address - Phone:301-552-8135
Mailing Address - Fax:
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3574
Practice Address - Country:US
Practice Address - Phone:301-552-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005436363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical