Provider Demographics
NPI:1679572507
Name:FRAZIER, JON DURWOOD (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:DURWOOD
Last Name:FRAZIER
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:PO BOX 2368
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2368
Mailing Address - Country:US
Mailing Address - Phone:812-474-1110
Mailing Address - Fax:812-474-1303
Practice Address - Street 1:700 N BURKHARDT RD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-2740
Practice Address - Country:US
Practice Address - Phone:812-474-1110
Practice Address - Fax:812-474-1303
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010428192085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00724152OtherRR MEDICARE TROC
IN100387080Medicaid
P00394815OtherRR MEDICARE
KY64030752Medicaid
KY64030752Medicaid
KY0204614Medicare PIN
KY00549001Medicare PIN
INP00724152OtherRR MEDICARE TROC
IN838350WWWMedicare PIN
IN236400EMedicare ID - Type Unspecified
KY00549001Medicare PIN