Healthcare Provider Details

I. General information

NPI: 1003472366
Provider Name (Legal Business Name): ELLIE FRAZEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELHAAM IRANMANESH

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 OVERLOOK DR
TEMPLE TERRACE FL
33617-5422
US

IV. Provider business mailing address

11215 METRO PKWY STE 1
FORT MYERS FL
33966-1206
US

V. Phone/Fax

Practice location:
  • Phone: 813-820-1520
  • Fax: 949-864-3647
Mailing address:
  • Phone: 813-842-4723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD215161
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME161342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: