Basic Information
| Provider Information | |||||||||
| NPI: | 1790758563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOWRY | ||||||||
| FirstName: | JEFFERSON | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 8TH AVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | 8173352670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 8TH AVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358151 | ||||||||
| FaxNumber: | 8173352670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 04/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | F0567 | TX | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 207Y00000X | F0567 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | F0567 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 760330807 | 01 | TX | TAX ID | OTHER | PR29609650002 | 01 | TX | CIGNA VENDOR NUMBER | OTHER | 2940798 | 01 | TX | AETNA PROVIDER # | OTHER | 00000074EP | 01 | TX | BLUE CROSS BLUE SHIELD ID | OTHER | 0310740-01 | 05 | TX | MEDICAID |