Provider Demographics
NPI:1174693782
Name:FRASIER, ROBERT W III (MDPC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:FRASIER
Suffix:III
Gender:M
Credentials:MDPC
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 2156
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2156
Mailing Address - Country:US
Mailing Address - Phone:505-753-6771
Mailing Address - Fax:505-747-0312
Practice Address - Street 1:612 N PASEO DE ONATE STE D
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2963
Practice Address - Country:US
Practice Address - Phone:505-753-6771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74158208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D35637Medicare UPIN
2123266Medicare ID - Type Unspecified