Provider Demographics
NPI:1477649218
Name:FOWLKES, THOMAS D (M D)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:D
Last Name:FOWLKES
Suffix:
Gender:M
Credentials:M D
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 1093
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-1093
Mailing Address - Country:US
Mailing Address - Phone:662-801-7508
Mailing Address - Fax:662-234-8531
Practice Address - Street 1:1916 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4114
Practice Address - Country:US
Practice Address - Phone:662-281-1306
Practice Address - Fax:662-281-1326
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13406207P00000X, 208D00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01508551Medicaid
MS5916714OtherCIGNA PIN
MS930003537Medicare ID - Type UnspecifiedMS MEDICARE
MS5916714OtherCIGNA PIN
MSP00320722Medicare ID - Type UnspecifiedRAILROAD MEDICARE