1609189760 NPI number — MR. ELONZO STAFON ABRAHAM JR. M.ED, CACI

Table of content: MR. ELONZO STAFON ABRAHAM JR. M.ED, CACI (NPI 1609189760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609189760 NPI number — MR. ELONZO STAFON ABRAHAM JR. M.ED, CACI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABRAHAM
Provider First Name:
ELONZO
Provider Middle Name:
STAFON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.ED, CACI
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609189760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 TOPEKA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02118-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-442-1499
Provider Business Mailing Address Fax Number:
617-442-1660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 TOPEKA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02118-2717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-442-1499
Provider Business Practice Location Address Fax Number:
617-442-1660
Provider Enumeration Date:
07/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  0902231 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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