Healthcare Provider Details

I. General information

NPI: 1366456972
Provider Name (Legal Business Name): PHILLIP PATRICK FOWLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E HIGHLAND DR STE 100
JONESBORO AR
72401-5144
US

IV. Provider business mailing address

5501 S OLIVE ST
PINE BLUFF AR
71603-7607
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-6040
  • Fax:
Mailing address:
  • Phone: 870-761-4761
  • Fax: 870-761-4761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2539
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: