Basic Information
| Provider Information | |||||||||
| NPI: | 1346284668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABRAHAM OWUSU DOMMEY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2510 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852142510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808219339 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 S LINDSAY RD | ||||||||
| Address2: | STE 123 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852971503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808219339 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | OWUSU DOMMEY | ||||||||
| AuthorizedOfficialFirstName: | ABRAHAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4808219339 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 26852 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 491176 | 05 | AZ | MEDICAID |