Provider Demographics
NPI:1225290406
Name:FOWLER, JEREMY DAVID (OD)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DAVID
Last Name:FOWLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 VETERANS MEMORIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-8694
Mailing Address - Country:US
Mailing Address - Phone:502-996-7450
Mailing Address - Fax:
Practice Address - Street 1:6501 VETERANS MEMORIAL PKWY
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-8694
Practice Address - Country:US
Practice Address - Phone:502-996-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003525A152W00000X
KY1811DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11875636OtherCAQH
KY7100428530Medicaid