Provider Demographics
NPI:1578588273
Name:KELLY J FRASIER M.D., P.A.
Entity Type:Organization
Organization Name:KELLY J FRASIER M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:FRASIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-687-2635
Mailing Address - Street 1:3804 21ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1012
Mailing Address - Country:US
Mailing Address - Phone:806-687-2635
Mailing Address - Fax:806-687-2637
Practice Address - Street 1:3804 21ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1012
Practice Address - Country:US
Practice Address - Phone:806-687-2635
Practice Address - Fax:806-687-2637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2952207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0056NSOtherBLUE CROSS BLUE SHIELD
TX00W893Medicare PIN
TXI61196Medicare UPIN