Provider Demographics
NPI:1073503405
Name:FOWLER, GARY MATTHEW (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:MATTHEW
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 1:191 CARAWAY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35594-5067
Mailing Address - Country:US
Mailing Address - Phone:205-487-1586
Mailing Address - Fax:205-487-1589
Practice Address - Street 1:191 CARAWAY DR
Practice Address - Street 2:SUITE A
Practice Address - City:WINFIELD
Practice Address - State:AL
Practice Address - Zip Code:35594-5067
Practice Address - Country:US
Practice Address - Phone:205-487-1586
Practice Address - Fax:205-487-1589
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000046678Medicaid
F82077Medicare UPIN
AL000046678Medicare ID - Type Unspecified