Healthcare Provider Details

I. General information

NPI: 1184626822
Provider Name (Legal Business Name): WAYNE A FOWLER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 CENTRAL ST
LOWELL MA
01852-1927
US

IV. Provider business mailing address

22 ROCKY HILL RD
ANDOVER MA
01810-6118
US

V. Phone/Fax

Practice location:
  • Phone: 978-458-4546
  • Fax: 978-934-9264
Mailing address:
  • Phone: 978-623-8195
  • Fax: 978-934-9264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4051
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: