Provider Demographics
NPI:1861486177
Name:FRASER, MALCOLM R (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:R
Last Name:FRASER
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 1:605 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3211
Mailing Address - Country:US
Mailing Address - Phone:352-799-5411
Mailing Address - Fax:352-544-2713
Practice Address - Street 1:605 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-799-5411
Practice Address - Fax:352-544-2713
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36199207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62242OtherBC/BS FLA
FL010065834OtherRAILROAD MEDICARE
FL039210300Medicaid
FL010066083OtherRAILROAD MEDICARE
FL010066171OtherRAILROAD MEDICARE
FL62242CMedicare PIN
FL62242DMedicare PIN
FL62242EMedicare PIN
FL010066171OtherRAILROAD MEDICARE