Provider Demographics
NPI:1417064403
Name:FOWLER, LARRY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JOHN
Last Name:FOWLER
Suffix:
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-0238
Mailing Address - Fax:352-265-0437
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0238
Practice Address - Fax:352-265-0437
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4806207ZP0102X, 207R00000X, 207ZC0500X
FLME105199207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103887902Medicaid
FL001415400Medicaid
TX103887901OtherCSHCN
FL001415400Medicaid
TXB43711Medicare UPIN
FLCM040ZMedicare PIN