Provider Demographics
NPI:1164659983
Name:FOWLER, ZACHARY ALAN (DO)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ALAN
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 1:1717 S UTICA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5346
Mailing Address - Country:US
Mailing Address - Phone:918-748-7557
Mailing Address - Fax:918-748-7514
Practice Address - Street 1:1717 S UTICA AVE STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5346
Practice Address - Country:US
Practice Address - Phone:918-748-7557
Practice Address - Fax:918-748-7514
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200294460BMedicaid
OK263258YMAEMedicare PIN