Provider Demographics
NPI:1104906452
Name:FRASER, CHARLES D JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:FRASER
Suffix:JR
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 1:6621 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2303
Mailing Address - Country:US
Mailing Address - Phone:832-826-5731
Mailing Address - Fax:832-825-1904
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723
Practice Address - Country:US
Practice Address - Phone:855-324-0091
Practice Address - Fax:512-380-7532
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG88402086S0120X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133148004OtherCSHCN
TX133148001Medicaid
81Z728Medicare PIN
TX133148001Medicaid
TX133148004OtherCSHCN