Provider Demographics
NPI:1417084690
Name:ROBERT W. FOWLER, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT W. FOWLER, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-644-1152
Mailing Address - Street 1:3010 COLBY ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2059
Mailing Address - Country:US
Mailing Address - Phone:510-644-1152
Mailing Address - Fax:510-666-1087
Practice Address - Street 1:3010 COLBY ST
Practice Address - Street 2:SUITE 110
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2059
Practice Address - Country:US
Practice Address - Phone:510-644-1152
Practice Address - Fax:510-666-1087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32648208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA88974Medicare UPIN
CA00C326480Medicare ID - Type Unspecified