Provider Demographics
NPI:1710004106
Name:FRAZIER, KENT LEE (OD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:LEE
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 SPLIT RAIL DR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64801-9198
Mailing Address - Country:US
Mailing Address - Phone:417-673-4066
Mailing Address - Fax:
Practice Address - Street 1:3200 LUSK DR
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-2028
Practice Address - Country:US
Practice Address - Phone:417-451-1119
Practice Address - Fax:417-451-2479
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3105152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU46428Medicare UPIN