Provider Demographics
NPI:1427020023
Name:FOWLE, GARY J (OD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:FOWLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:120 MARCELL DR NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1362
Mailing Address - Country:US
Mailing Address - Phone:616-866-0140
Mailing Address - Fax:616-866-8694
Practice Address - Street 1:120 MARCELL DR NE
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1362
Practice Address - Country:US
Practice Address - Phone:616-866-0140
Practice Address - Fax:616-866-8694
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901002906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780888081OtherGROUP NPI
1427020023OtherINDIVIDUAL NPI
MI5106316Medicaid
MI5106316Medicaid
MIT33057Medicare UPIN