Provider Demographics
NPI:1306804273
Name:FRY, CONSTANCE LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:CONSTANCE
Middle Name:LOUISE
Last Name:FRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 CRESTHAVEN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0809
Mailing Address - Country:US
Mailing Address - Phone:901-866-8864
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3452
Practice Address - Country:US
Practice Address - Phone:901-448-6650
Practice Address - Fax:901-302-2486
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2567207W00000X
TN68123207W00000X
LAMD.020017207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182388203Medicaid
AR306939001Medicaid
TX182388204OtherCSHCN
TNQ085226Medicaid
MS200006375Medicaid
MO200133851Medicaid