Provider Demographics
NPI:1043246366
Name:FOWLER, BURT N (MD)
Entity Type:Individual
Prefix:DR
First Name:BURT
Middle Name:N
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S UNION BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3117
Mailing Address - Country:US
Mailing Address - Phone:719-577-4040
Mailing Address - Fax:
Practice Address - Street 1:175 S UNION BLVD
Practice Address - Street 2:#115
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3113
Practice Address - Country:US
Practice Address - Phone:719-365-5445
Practice Address - Fax:719-365-5530
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44178208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42653371Medicaid
CO808837Medicare PIN
COC97767Medicare UPIN