Provider Demographics
NPI:1215040316
Name:FOWLER, CYNTHIA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4839 NE MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-3386
Mailing Address - Country:US
Mailing Address - Phone:503-953-4491
Mailing Address - Fax:971-200-2662
Practice Address - Street 1:4839 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3386
Practice Address - Country:US
Practice Address - Phone:503-953-4491
Practice Address - Fax:971-200-2662
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA664732084P0800X
ORMD1536492084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI13244Medicare UPIN
K11269Medicare ID - Type Unspecified