Provider Demographics
NPI:1386698009
Name:FRAZIER, STEPHEN DALE (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DALE
Last Name:FRAZIER
Suffix:
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:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-3716
Mailing Address - Fax:319-233-1630
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3716
Practice Address - Fax:319-233-1630
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA329772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0193102Medicaid
IA421417307D4OtherJOHN DEERE HEALTH INS P
IA49304OtherWELLMARK INS PLAN
IA49304Medicare ID - Type Unspecified
IA0193102Medicaid