Basic Information
| Provider Information | |||||||||
| NPI: | 1548223381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABRAHAM | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
| FaxNumber: | 5032156644 | ||||||||
| Practice Location | |||||||||
| Address1: | 9427 SW BARNES ROAD | ||||||||
| Address2: | SUITE 498 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032160900 | ||||||||
| FaxNumber: | 5032160950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | MD29208 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | MD0048397 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | MD29208 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0001X | MD29208 | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 500609590 | 05 | OR | MEDICAID | P00873816 | 01 | OR | RR MEDICARE | OTHER | P00991145 | 01 | WA | RR MEDICARE | OTHER |