Provider Demographics
NPI:1366456972
Name:FOWLER, PHILLIP PATRICK (OD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PATRICK
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 1:5501 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7607
Mailing Address - Country:US
Mailing Address - Phone:870-761-4761
Mailing Address - Fax:870-761-4761
Practice Address - Street 1:2100 E HIGHLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5144
Practice Address - Country:US
Practice Address - Phone:870-972-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2539152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152051722Medicaid
ARP00073866OtherRAILROAD MEDICARE
MO318407004OtherMISSOURI MEDICAID
AR0852830001Medicare NSC
ARP00073866OtherRAILROAD MEDICARE