Provider Demographics
NPI:1386626240
Name:FOWLER, REGINALD JAYE JR (MD)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:JAYE
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 1:3001 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-0383
Mailing Address - Fax:336-768-1737
Practice Address - Street 1:3001 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-765-0383
Practice Address - Fax:336-768-1737
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301462207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891351FMedicaid
G51567Medicare UPIN
NC2021577Medicare PIN