Healthcare Provider Details

I. General information

NPI: 1104906452
Provider Name (Legal Business Name): CHARLES D. FRASER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MUELLER BLVD
AUSTIN TX
78723
US

IV. Provider business mailing address

6621 FANNIN ST
HOUSTON TX
77030-2303
US

V. Phone/Fax

Practice location:
  • Phone: 855-324-0091
  • Fax: 512-380-7532
Mailing address:
  • Phone: 832-826-5731
  • Fax: 832-825-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberG8840
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG8840
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: