Provider Demographics
NPI:1609894773
Name:FRASIER, KELLY J (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:FRASIER
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 1:350 E INTERSTATE 20
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-1119
Mailing Address - Country:US
Mailing Address - Phone:817-784-0222
Mailing Address - Fax:817-417-0981
Practice Address - Street 1:350 E INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-1119
Practice Address - Country:US
Practice Address - Phone:817-784-0222
Practice Address - Fax:817-417-0981
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2952207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161608201Medicaid
I61196Medicare UPIN
TX8F3694Medicare PIN