Provider Demographics
NPI:1326215559
Name:FOWLER, GREGORY M (OD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
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 1:893 WINDMILL LANE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809
Mailing Address - Country:US
Mailing Address - Phone:706-854-7779
Mailing Address - Fax:706-854-7668
Practice Address - Street 1:4469 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-854-7779
Practice Address - Fax:706-854-7668
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001422152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCCLWMedicare PIN