Provider Demographics
NPI:1598757684
Name:FRAYER, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:FRAYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E MAUMEE ST
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-2015
Mailing Address - Country:US
Mailing Address - Phone:260-667-5131
Mailing Address - Fax:260-665-7803
Practice Address - Street 1:306 E MAUMEE ST STE 303
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2044
Practice Address - Country:US
Practice Address - Phone:260-667-5685
Practice Address - Fax:260-667-5564
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050884A207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104529434Medicaid
IN200256660Medicaid
IN200256660Medicaid
IN930129126OtherRAIL ROAD MEDICARE
H06656Medicare UPIN
MI104529434Medicaid