Provider Demographics
NPI:1619941879
Name:LOWDER, JERRY LANE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LANE
Last Name:LOWDER
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 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-747-1402
Mailing Address - Fax:314-362-3328
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DIV OBGYN PELVIC MED/RECONSTRUCT SURG, STE 710
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-747-1402
Practice Address - Fax:314-362-3328
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013044288207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200011086Medicaid
ILENROLLEDMedicaid
PA090234D5LMedicare ID - Type Unspecified