Basic Information
| Provider Information | |||||||||
| NPI: | 1508077355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRAEGER | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1867 E FIR AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593255809 | ||||||||
| FaxNumber: | 5593255838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1867 E FIR AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593255809 | ||||||||
| FaxNumber: | 5593255838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 10/02/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A115013 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | A115013 | 01 | CA | MEDICAL LICENSE | OTHER |