Basic Information
| Provider Information | |||||||||
| NPI: | 1942485289 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABRAHAM | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 13001 SOUTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | LOXAHATCHEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334709203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778322652 | ||||||||
| FaxNumber: | 8007929021 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 JFK DR | ||||||||
| Address2: | |||||||||
| City: | ATLANTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334621151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614328935 | ||||||||
| FaxNumber: | 5614328937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2008 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME102232 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MT186819 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 390200000X | 01 | PA | TAXONOMY | OTHER |