Provider Demographics
NPI:1073609376
Name:FOWLER, CHAD RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:RYAN
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 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1032 CROSSWINDS CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385
Practice Address - Country:US
Practice Address - Phone:844-853-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009012785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113662Medicaid
ILK21028Medicare ID - Type Unspecified
IL036113662Medicaid