Provider Demographics
NPI:1881611887
Name:JACK E ABRAMS M D PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JACK E ABRAMS M D PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:ABRAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-304-9494
Mailing Address - Street 1:4800 N 22ND ST STE 200
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:
Mailing Address - Fax:
Practice Address - Street 1:6450 MEDICAL CENTER ST
Practice Address - Street 2:#100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-2405
Practice Address - Country:US
Practice Address - Phone:702-304-9494
Practice Address - Fax:702-304-9495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9777152WC0802X
261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic SurgeryGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018382Medicaid
NV002018382Medicaid
NVH17955Medicare UPIN