Healthcare Provider Details

I. General information

NPI: 1174994636
Provider Name (Legal Business Name): ABRAHAM JOSSUE LAJARA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 BROADWAY
FORT MYERS FL
33901-8005
US

IV. Provider business mailing address

3660 BROADWAY
FORT MYERS FL
33901-8005
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-2316
  • Fax: 239-936-3099
Mailing address:
  • Phone: 239-936-2316
  • Fax: 239-936-3099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number97966
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number97966
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME145509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: