Provider Demographics
NPI:1083904841
Name:FOWLER, MATTHEW BRYAN (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRYAN
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4316
Mailing Address - Country:US
Mailing Address - Phone:918-298-2264
Mailing Address - Fax:918-298-0923
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-4316
Practice Address - Country:US
Practice Address - Phone:918-298-2264
Practice Address - Fax:918-298-0923
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine