Healthcare Provider Details

I. General information

NPI: 1871572495
Provider Name (Legal Business Name): JIMMY DEAN FOWLER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 N DUNCAN BYP
UNION SC
29379-2667
US

IV. Provider business mailing address

PO BOX 606
UNION SC
29379-0606
US

V. Phone/Fax

Practice location:
  • Phone: 864-429-5404
  • Fax: 864-429-5402
Mailing address:
  • Phone: 864-429-5404
  • Fax: 864-429-5402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16124
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: