Provider Demographics
NPI:1134471592
Name:FOWLER, JACKSON ESTES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:ESTES
Last Name:FOWLER
Suffix:JR
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 1:1307 BEACHVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-5007
Mailing Address - Country:US
Mailing Address - Phone:410-268-1757
Mailing Address - Fax:
Practice Address - Street 1:1307 BEACHVIEW RD
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-5007
Practice Address - Country:US
Practice Address - Phone:410-268-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101021057208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology