Healthcare Provider Details

I. General information

NPI: 1255401063
Provider Name (Legal Business Name): ABIGAIL LEE HABERMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 NW CALLOWAY DR
CORVALLIS OR
97330-9598
US

IV. Provider business mailing address

690 NW CALLOWAY DR
CORVALLIS OR
97330-9598
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-2757
  • Fax: 541-754-3584
Mailing address:
  • Phone: 541-754-2757
  • Fax: 541-754-3584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD16039
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: