Provider Demographics
NPI:1699743989
Name:LOWE, JACK L (OD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:LOWE
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 1:1851 N WEBB RD
Mailing Address - Street 2:ATTN FLR2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-3413
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:15 N HIGHLAND
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720
Practice Address - Country:US
Practice Address - Phone:620-431-3250
Practice Address - Fax:620-431-3272
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS09113152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP00148609OtherRAILROAD MEDICARE
KSP00148609OtherRAILROAD MEDICARE
KST43659Medicare UPIN