Provider Demographics
NPI:1316989353
Name:FRASER, JOHN JOSEPH JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
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 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:PROVIDER ENROLLMENT-RT. 1022
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-747-0890
Mailing Address - Fax:409-772-0885
Practice Address - Street 1:11398 BANDERA RD STE 201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78250-6827
Practice Address - Country:US
Practice Address - Phone:210-543-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3966207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138402603Medicaid
TX138402613Medicaid
TX81Z135OtherBLUE CROSS BLUE SHIELD OF TEXAS
TX8L4344Medicare PIN
TXC15733Medicare UPIN
TX138402613Medicaid