Basic Information
| Provider Information | |||||||||
| NPI: | 1659459808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABRAHAM | ||||||||
| FirstName: | BOBBY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3900 ESPLANADE WAY | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323110802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504313867 | ||||||||
| FaxNumber: | 8504313879 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 ESPLANADE WAY | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323110802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504313867 | ||||||||
| FaxNumber: | 8504313879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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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 | 207R00000X | ME93170 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001239900 | 05 | FL | MEDICAID |