Provider Demographics
NPI:1124254933
Name:ABRAHAM, RONNIE M (MD)
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:M
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3160
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-3160
Mailing Address - Country:US
Mailing Address - Phone:805-548-1550
Mailing Address - Fax:805-623-1595
Practice Address - Street 1:3440 EMPRESA DR STE B
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:805-548-1550
Practice Address - Fax:805-623-1595
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC159083207ND0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology