Provider Demographics
NPI:1386318137
Name:ABRAHAM, JUSTIN (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 TIMBERS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-1480
Mailing Address - Country:US
Mailing Address - Phone:847-418-6049
Mailing Address - Fax:
Practice Address - Street 1:1100 JOHNSON FY RD NE STE 108
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1733
Practice Address - Country:US
Practice Address - Phone:404-531-9988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA16542096058OtherDRIVER'S LICENSE