Provider Demographics
NPI:1952500159
Name:ABRAHAM, MANOJ (OD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:
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 1:1505 STONE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-1147
Mailing Address - Country:US
Mailing Address - Phone:630-452-6290
Mailing Address - Fax:
Practice Address - Street 1:1251 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 331
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6478
Practice Address - Country:US
Practice Address - Phone:817-310-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009950152W00000X
TX8563T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist