Provider Demographics
NPI:1780609362
Name:FYKE, FRAZIER EARL III (MD)
Entity type:Individual
Prefix:
First Name:FRAZIER
Middle Name:EARL
Last Name:FYKE
Suffix:III
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 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:901-227-3255
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:501 MARSHALL ST
Practice Address - Street 2:STE 104
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1651
Practice Address - Country:US
Practice Address - Phone:601-969-6404
Practice Address - Fax:601-973-4541
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10477207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116537Medicaid
MS00116537Medicaid
MS060000040Medicare ID - Type Unspecified
MSP01127001OtherRAILROAD UMC
MSB30676Medicare UPIN
MSP00644731Medicare PIN
MS00116537Medicaid
MS512I060052Medicare PIN