Healthcare Provider Details

I. General information

NPI: 1306804273
Provider Name (Legal Business Name): CONSTANCE LOUISE FRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MADISON AVE STE 200
MEMPHIS TN
38103-3452
US

IV. Provider business mailing address

1068 CRESTHAVEN RD STE 300
MEMPHIS TN
38119-0809
US

V. Phone/Fax

Practice location:
  • Phone: 901-448-6650
  • Fax: 901-302-2486
Mailing address:
  • Phone: 901-866-8864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberJ2567
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number68123
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD.020017
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: