Provider Demographics
NPI:1982760690
Name:FRASER, OWEN D (MD)
Entity type:Individual
Prefix:MR
First Name:OWEN
Middle Name:D
Last Name:FRASER
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 1:1805 W COLONIAL DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7013
Mailing Address - Country:US
Mailing Address - Phone:407-578-9142
Mailing Address - Fax:407-578-8616
Practice Address - Street 1:1805 W COLONIAL DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7013
Practice Address - Country:US
Practice Address - Phone:407-578-9142
Practice Address - Fax:407-578-8616
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030256208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058757500Medicaid
FL48911Medicare ID - Type Unspecified
D55507Medicare UPIN