Provider Demographics
NPI:1487334454
Name:WIDJAJA, ABRAHAM W (DC)
Entity type:Individual
Prefix:DR
First Name:ABRAHAM
Middle Name:W
Last Name:WIDJAJA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 BRYANT AVE S APT 201
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3140
Mailing Address - Country:US
Mailing Address - Phone:712-212-1236
Mailing Address - Fax:
Practice Address - Street 1:2201 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2738
Practice Address - Country:US
Practice Address - Phone:612-377-7760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7123111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor