Provider Demographics
NPI:1073017265
Name:FRYER, VINCENT LUCAS DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:LUCAS DAVID
Last Name:FRYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 SUNNY LN APT C
Mailing Address - Street 2:
Mailing Address - City:SUAMICO
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7821
Mailing Address - Country:US
Mailing Address - Phone:801-554-4882
Mailing Address - Fax:
Practice Address - Street 1:2329 SUNNY LN APT C
Practice Address - Street 2:
Practice Address - City:SUAMICO
Practice Address - State:WI
Practice Address - Zip Code:54313-7821
Practice Address - Country:US
Practice Address - Phone:801-554-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71760-20208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice