Provider Demographics
NPI:1104848274
Name:FOWLER, GLENN W (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:W
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:PO BOX 54559
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0559
Mailing Address - Country:US
Mailing Address - Phone:714-456-8068
Mailing Address - Fax:714-456-3765
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-8068
Practice Address - Fax:714-456-3765
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC272602084N0402X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C272600Medicaid
CA00C272600Medicaid
CAAF0047159OtherDEA
CAA33320Medicare UPIN