Provider Demographics
NPI:1871572495
Name:FOWLER, JIMMY DEAN JR (MD)
Entity type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:DEAN
Last Name:FOWLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29379-0606
Mailing Address - Country:US
Mailing Address - Phone:864-429-5404
Mailing Address - Fax:864-429-5402
Practice Address - Street 1:219 N DUNCAN BYP
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-2667
Practice Address - Country:US
Practice Address - Phone:864-429-5404
Practice Address - Fax:864-429-5402
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC161247Medicaid
SCF67502Medicare UPIN