Basic Information
| Provider Information | |||||||||
| NPI: | 1255561379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRASER | ||||||||
| FirstName: | DONESSA | ||||||||
| MiddleName: | ARETHA | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2389 WESLEY CHAPEL RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300352819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044699867 | ||||||||
| FaxNumber: | 8778895105 | ||||||||
| Practice Location | |||||||||
| Address1: | 2389 WESLEY CHAPEL RD STE 102 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300352819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044699867 | ||||||||
| FaxNumber: | 8778895105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31828 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 89269 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1255561379 | 05 | AL | MEDICAID |