Provider Demographics
NPI:1477563666
Name:FOWLER, ELIZABETH WENTWORTH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:WENTWORTH
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:ELIZABETH
Other - Last Name:WENTWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:595 PRICE AVE
Mailing Address - Street 2:STE E
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063
Mailing Address - Country:US
Mailing Address - Phone:650-369-4147
Mailing Address - Fax:650-369-0813
Practice Address - Street 1:595 PRICE AVE
Practice Address - Street 2:STE E
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063
Practice Address - Country:US
Practice Address - Phone:650-369-4147
Practice Address - Fax:650-369-4147
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72932208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics