Provider Demographics
NPI:1417172438
Name:LOWERY, BENJAMIN ROUSSEL (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROUSSEL
Last Name:LOWERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-1523
Mailing Address - Country:US
Mailing Address - Phone:479-571-6038
Mailing Address - Fax:479-582-0222
Practice Address - Street 1:3344 N FUTRALL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-443-5316
Practice Address - Fax:479-582-7389
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-54722085R0202X, 2085R0202X
AR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5I127OtherAR BC/BS
AR192007001Medicaid
AL129141Medicaid
AL051116427OtherBCBS
AL051116432OtherBCBS
MS07772221Medicaid
AL129137Medicaid
AL051116433OtherBCBS
AL129138Medicaid
AL129144Medicaid
AL051116439OtherBCBS
AL051116440OtherBCBS
AL051116431OtherBCBS
AL129140Medicaid
AL129145Medicaid
AR192007001Medicaid
AL051116428OtherBCBS
AL051116430OtherBCBS
AL129147Medicaid
AR5I127OtherAR BC/BS
AL129139Medicaid
AL129142Medicaid
AL129143Medicaid
AL129142Medicaid
MS07772221Medicaid
AL102I304741Medicare PIN