Provider Demographics
NPI:1215026760
Name:FRASER, COSMO LYLE (MD)
Entity Type:Individual
Prefix:MR
First Name:COSMO
Middle Name:LYLE
Last Name:FRASER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:220 STANDIFORD AVE
Mailing Address - Street 2:STE F
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1159
Mailing Address - Country:US
Mailing Address - Phone:209-579-5628
Mailing Address - Fax:209-579-5637
Practice Address - Street 1:2115 E ONSTOTT RD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-1556
Practice Address - Country:US
Practice Address - Phone:530-751-0339
Practice Address - Fax:530-751-0449
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2023-10-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC40203207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C402030Medicaid
CA00C402030Medicare ID - Type Unspecified
CA00C402030Medicaid