=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366456972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP PATRICK FOWLER O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 E HIGHLAND DR STE 100
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-972-6040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 S OLIVE ST
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-7607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-761-4761
-----------------------------------------------------
Fax | 870-761-4761
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2539
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------