Healthcare Provider Details

I. General information

NPI: 1326113234
Provider Name (Legal Business Name): JOHN FOWLKES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-0001
US

IV. Provider business mailing address

800 ROSE ST
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5404
  • Fax:
Mailing address:
  • Phone: 859-323-5404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number32794
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: