Basic Information
| Provider Information | |||||||||
| NPI: | 1306874920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABRAHAM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 HIGHWAY 59 S | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567014331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186814747 | ||||||||
| FaxNumber: | 2186832595 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 HIGHWAY 59 S | ||||||||
| Address2: | |||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567014331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186814747 | ||||||||
| FaxNumber: | 2186832595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 45176 | MN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 12208 | 05 | MN | MEDICAID | 64G77AB | 01 | MN | MNBS # | OTHER | HP38297 | 01 | MN | HEALTHPARTNERS # | OTHER | 1000386 | 01 | MN | MEDICA # | OTHER | 1000692 | 01 | MN | MEDICA # | OTHER | 169872 | 01 | MN | UCARE # | OTHER | 22280 | 01 | MN | NDBS # | OTHER | 317S2AB | 01 | MN | MNBS # | OTHER | 121635000 | 05 | MN | MEDICAID | 1642950 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | DA9021032617 | 01 | MN | PREFERRED ONE # | OTHER | DA9071032617 | 01 | MN | PREFERRED ONE # | OTHER | 25842 | 01 | MN | NDBS # | OTHER |