Healthcare Provider Details

I. General information

NPI: 1700090685
Provider Name (Legal Business Name): RONALD DERALD FRYAR JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 LEXINGTON DRIVE
INGLESIDE TX
78362
US

IV. Provider business mailing address

1130 LA MIRADA
PORTLAND TX
78374-4133
US

V. Phone/Fax

Practice location:
  • Phone: 361-776-4077
  • Fax:
Mailing address:
  • Phone: 361-643-5833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: