Provider Demographics
NPI:1184626822
Name:FOWLER, WAYNE A (OD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:A
Last Name:FOWLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22 ROCKY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-6118
Mailing Address - Country:US
Mailing Address - Phone:978-623-8195
Mailing Address - Fax:978-934-9264
Practice Address - Street 1:9 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1927
Practice Address - Country:US
Practice Address - Phone:978-458-4546
Practice Address - Fax:978-934-9264
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4051152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3193OtherANTHEM BS
MA40485OtherNH/VERMONT BC/BS
MA0312479Medicaid
MA41642OtherJOHN HANCOCL/CHILDERN
MA774609OtherTUFTS HEALTH PLAN
MA174713OtherCIGNA
MA158296XXOtherPHCS
MA151507OtherHARVARD PILGRIM
MA35222OtherFALLON HEALTH CARE
MA3200852OtherAETNA
MA980952OtherNTEWORKHEALTH
MAW16119OtherBC/BS OF MASS
MA41642OtherJOHN HANCOCL/CHILDERN
MAU68881Medicare UPIN