Healthcare Provider Details

I. General information

NPI: 1376540104
Provider Name (Legal Business Name): LARRY L ABRAHAM D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N MAIN ST
EL DORADO KS
67042-2021
US

IV. Provider business mailing address

321 N MAIN ST
EL DORADO KS
67042-2021
US

V. Phone/Fax

Practice location:
  • Phone: 316-321-2050
  • Fax: 316-321-3309
Mailing address:
  • Phone: 316-321-2050
  • Fax: 316-321-3309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number12-00110
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: