Healthcare Provider Details

I. General information

NPI: 1801100623
Provider Name (Legal Business Name): PATRICK FOWLER O.D. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 S OLIVE ST
PINE BLUFF AR
71603-7607
US

IV. Provider business mailing address

5501 S OLIVE ST
PINE BLUFF AR
71603-7607
US

V. Phone/Fax

Practice location:
  • Phone: 870-761-4761
  • Fax: 870-534-7362
Mailing address:
  • Phone: 870-761-4761
  • Fax: 870-534-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. PHILLIP PATRICK FOWLER
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 870-761-4761