Provider Demographics
NPI:1023303138
Name:FRAZIER, KENYATTA JAMAL (MD)
Entity type:Individual
Prefix:DR
First Name:KENYATTA
Middle Name:JAMAL
Last Name:FRAZIER
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 1:5140 NE 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-5727
Mailing Address - Country:US
Mailing Address - Phone:843-608-0928
Mailing Address - Fax:
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA158054207P00000X
FLME125282207P00000X
IL036.135877207P00000X
SCMMD.38329MD207P00000X
TXQ5652207P00000X
IL125-059278207P00000X
LA311112207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine