Provider Demographics
NPI:1871504100
Name:FOWLKES, LISA FAY (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:FAY
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 BAXTER ST
Mailing Address - Street 2:PO BOX 7695
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3712
Mailing Address - Country:US
Mailing Address - Phone:706-389-3420
Mailing Address - Fax:706-389-3411
Practice Address - Street 1:1230 BAXTER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3712
Practice Address - Country:US
Practice Address - Phone:706-389-3420
Practice Address - Fax:706-389-3411
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA48289208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000862364BMedicaid
GA11SCFVHMedicare ID - Type Unspecified
GA000862364BMedicaid