Provider Demographics
NPI:1417989476
Name:FOWLER, CARL (MD)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:
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 685
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:1305 N OAKLAND BLVD
Practice Address - Street 2:ER DEPARTMENT
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327
Practice Address - Country:US
Practice Address - Phone:248-666-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICF045243207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104195483Medicaid
MICF045243OtherBCBS
0M92460014Medicare ID - Type Unspecified
MI104195483Medicaid
MI930089934Medicare PIN