Provider Demographics
NPI:1699768689
Name:PHILLIPS, ROBERT LOWELL (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LOWELL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 886
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-0886
Mailing Address - Country:US
Mailing Address - Phone:904-259-6797
Mailing Address - Fax:904-387-0969
Practice Address - Street 1:534 S 5TH ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2602
Practice Address - Country:US
Practice Address - Phone:904-259-6797
Practice Address - Fax:904-259-5230
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2018-04-06
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
FLOB233152W00000X
FLOPC930152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084322900Medicaid
FL084322901Medicaid
FL19344Medicare ID - Type Unspecified2ND OFFICE LOCATION
FLT83944AMedicare UPIN
FL19344AMedicare ID - Type Unspecified
FLT83944Medicare UPIN
FL5004760001Medicare NSC