Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 4210 | SC |
NPI | 1528143898 |
---|---|
Provider Name | John Frazier |
First Address | Middle Village, NY 11379-5329 |
Second Address | Middle Village, NY 11379-5329 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2006 |
Last Update Date | 03/06/2009 |