Provider Demographics
NPI:1003472366
Name:FRAZEY, ELLIE (MD)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:
Last Name:FRAZEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELHAAM
Other - Middle Name:
Other - Last Name:IRANMANESH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11215 METRO PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:813-842-4723
Mailing Address - Fax:
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1613422084N0400X
390200000X
ORMD2151612084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program