Provider Demographics
NPI:1841282860
Name:FISHER, LOWELL R (DO)
Entity type:Individual
Prefix:
First Name:LOWELL
Middle Name:R
Last Name:FISHER
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 1:600 BLUES LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8022
Mailing Address - Country:US
Mailing Address - Phone:573-364-8822
Mailing Address - Fax:573-341-5969
Practice Address - Street 1:600 BLUES LAKE PKWY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8022
Practice Address - Country:US
Practice Address - Phone:573-364-8822
Practice Address - Fax:573-341-5969
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101006129208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO965674083Medicare PIN
MIA78345Medicare UPIN