Provider Demographics
NPI:1275652877
Name:LOWDER, GARY WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:LOWDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST STE 355
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7363
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2408 BROADMOOR BLVD STE B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2994
Practice Address - Country:US
Practice Address - Phone:183-807-0525
Practice Address - Fax:183-807-1077
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01617R207Q00000X
LA10617R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1683710Medicaid
LAG15571Medicare UPIN
LA1683710Medicaid