Healthcare Provider Details

I. General information

NPI: 1720172380
Provider Name (Legal Business Name): JAY B FRAZER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 S REED RD SUITE 104
KOKOMO IN
46902-3828
US

IV. Provider business mailing address

3611 S REED RD SUITE 104
KOKOMO IN
46902-3828
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-5892
  • Fax: 765-453-8262
Mailing address:
  • Phone: 765-453-5892
  • Fax: 765-453-8262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000435
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: