Basic Information
Provider Information | |||||||||
NPI: | 1912902800 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RICHARDS | ||||||||
FirstName: | FRASER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2202 N FORBES BLVD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857451412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208863432 | ||||||||
FaxNumber: | 5208860169 | ||||||||
Practice Location | |||||||||
Address1: | 6567 E CARONDELET DR | ||||||||
Address2: | STE 225 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857106152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208863432 | ||||||||
FaxNumber: | 5208860169 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2005 | ||||||||
LastUpdateDate: | 11/02/2011 | ||||||||
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 | 174400000X | 37745 | AZ | N |   | Other Service Providers | Specialist |   | 207RI0011X | 37745 | AZ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 37745 | AZ | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | P00958349 | 01 | AZ | RR MEDICARE | OTHER | 286043 | 05 | AZ |   | MEDICAID | 37745 | 01 | AZ | STATE LICENSE | OTHER | N8395 | 01 | AR | STATE LICENSE | OTHER | BR1890652 | 01 |   | DEA NUMBER | OTHER |