Provider Demographics
NPI:1710456496
Name:FRASER, LOUCHLYN TREMAINE (OD)
Entity Type:Individual
Prefix:
First Name:LOUCHLYN
Middle Name:TREMAINE
Last Name:FRASER
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 1:11954 NARCOOSSEE RD STE 2
Mailing Address - Street 2:PMB 234
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832-6998
Mailing Address - Country:US
Mailing Address - Phone:312-972-1765
Mailing Address - Fax:
Practice Address - Street 1:1150 E VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3579
Practice Address - Country:US
Practice Address - Phone:312-972-1765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-25
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011261152W00000X
FLOPC5686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist