Basic Information
Provider Information | |||||||||
NPI: | 1679572507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRAZIER | ||||||||
FirstName: | JON | ||||||||
MiddleName: | DURWOOD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2368 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462062368 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124741110 | ||||||||
FaxNumber: | 8124741303 | ||||||||
Practice Location | |||||||||
Address1: | 700 N BURKHARDT RD | ||||||||
Address2: |   | ||||||||
City: | EVANSVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 477152740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8124741110 | ||||||||
FaxNumber: | 8124741303 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2005 | ||||||||
LastUpdateDate: | 06/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 01042819 | IN | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | P00724152 | 01 | IN | RR MEDICARE TROC | OTHER | 100387080 | 05 | IN |   | MEDICAID | P00394815 | 01 |   | RR MEDICARE | OTHER | 64030752 | 05 | KY |   | MEDICAID |