Provider Demographics
NPI:1487645966
Name:FOWNES, DOUGLAS R (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:FOWNES
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:723 PARK RIDGE LN
Practice Address - Street 2:
Practice Address - City:NORTH FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1385
Practice Address - Country:US
Practice Address - Phone:920-926-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI080076569OtherRAILROAD MEDICARE
WI30204900Medicaid
WI000722245Medicare PIN
WI21386OtherTOUCHPOINT
WI12686OtherDEAN
WIWI0164OtherJOHN DEERE
WI30204900Medicaid