1174511794 NPI number — DR. MATTHEW MACK ABRAHAM M.D.

Table of content: DR. MATTHEW MACK ABRAHAM M.D. (NPI 1174511794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174511794 NPI number — DR. MATTHEW MACK ABRAHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABRAHAM
Provider First Name:
MATTHEW
Provider Middle Name:
MACK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1174511794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2851 JOHNSTON STREET
Provider Second Line Business Mailing Address:
PMB 517
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70503-3243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-561-8508
Provider Business Mailing Address Fax Number:
833-561-2443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 ASMA BLVD
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-3858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-289-5605
Provider Business Practice Location Address Fax Number:
337-289-5609
Provider Enumeration Date:
10/07/2005

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: 207Q00000X , with the licence number:  024082 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS1201X , with the licence number: 024082 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1488909 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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