Provider Demographics
NPI:1689601122
Name:EBERSOLE, LOWELL D (DO)
Entity Type:Individual
Prefix:DR
First Name:LOWELL
Middle Name:D
Last Name:EBERSOLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 E MURDOCK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3054
Mailing Address - Country:US
Mailing Address - Phone:316-689-9379
Mailing Address - Fax:316-689-9118
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-689-9379
Practice Address - Fax:316-689-9118
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0529885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100427230AMedicaid
003719239OtherMEDICARE
003719239OtherMEDICARE
KS103820Medicare ID - Type Unspecified
P00170724OtherRAIL ROAD MEDICARE