Basic Information
| Provider Information | |||||||||
| NPI: | 1023051588 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRAZER | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AU.D. , PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 11645 WILSHIRE BLVD | ||||||||
| Address2: | SUITE# 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104775558 | ||||||||
| FaxNumber: | 3104777281 | ||||||||
| Practice Location | |||||||||
| Address1: | 11645 WILSHIRE BLVD STE 601A | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900251708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109090180 | ||||||||
| FaxNumber: | 3109193181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | AU651 | CA | N | Other Service Providers | Specialist | 231H00000X | AU651 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | AU0006510 | 05 | CA | MEDICAID |