Healthcare Provider Details

I. General information

NPI: 1891198149
Provider Name (Legal Business Name): DESALEGN ABRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

PO BOX 418056 DOCTORS COMMUNITY MEDICAL GROUP LLC
BOSTON MA
02241-8056
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8130
  • Fax:
Mailing address:
  • Phone: 301-552-8135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0005436
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: