Provider Demographics
NPI:1114056702
Name:FRASER, LESLIE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:JOHN
Last Name:FRASER
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 1:168 S HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-2040
Mailing Address - Country:US
Mailing Address - Phone:517-437-5125
Mailing Address - Fax:
Practice Address - Street 1:168 S HOWELL ST
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-2040
Practice Address - Country:US
Practice Address - Phone:517-437-5125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301054240207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F64866Medicare UPIN