Provider Demographics
NPI:1720172380
Name:FRAZER, JAY B (DPM)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:B
Last Name:FRAZER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 S REED RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3828
Mailing Address - Country:US
Mailing Address - Phone:765-453-5892
Mailing Address - Fax:765-453-8262
Practice Address - Street 1:3611 S REED RD
Practice Address - Street 2:SUITE 104
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3828
Practice Address - Country:US
Practice Address - Phone:765-453-5892
Practice Address - Fax:765-453-8262
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000435213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0351930001OtherDMERC
IN000000345131OtherANTHEM BCBS
INT34696Medicare UPIN
IN367950DMedicare ID - Type Unspecified