Provider Demographics
NPI:1093777856
Name:FOWLER, JEFFREY B (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
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:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:PRIEST RIVER
Mailing Address - State:ID
Mailing Address - Zip Code:83856-0729
Mailing Address - Country:US
Mailing Address - Phone:208-448-2321
Mailing Address - Fax:208-448-1317
Practice Address - Street 1:314 E ALBENI HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-0729
Practice Address - Country:US
Practice Address - Phone:208-448-2321
Practice Address - Fax:208-448-1317
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-49207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002406600Medicaid
ID002406600Medicaid
ID1371022Medicare PIN
ID002406600Medicaid