Provider Demographics
NPI:1790758563
Name:LOWRY, JEFFERSON ROY (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:ROY
Last Name:LOWRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 8TH AVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-335-8151
Mailing Address - Fax:817-335-2670
Practice Address - Street 1:1250 8TH AVE
Practice Address - Street 2:SUITE 135
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-335-8151
Practice Address - Fax:817-335-2670
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0567204E00000X, 207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760330807OtherTAX ID
TXPR29609650002OtherCIGNA VENDOR NUMBER
TX2940798OtherAETNA PROVIDER #
TX00000074EPOtherBLUE CROSS BLUE SHIELD ID
TX0310740-01Medicaid
TX00762LMedicare ID - Type UnspecifiedPROVIDER #
TX0310740-01Medicaid