Provider Demographics
NPI:1497301873
Name:FOWLER, TERESA (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH ST # BA2720
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-5704
Mailing Address - Country:US
Mailing Address - Phone:706-721-1160
Mailing Address - Fax:706-721-1158
Practice Address - Street 1:1120 15TH ST # BA-2720
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-5704
Practice Address - Country:US
Practice Address - Phone:706-721-1160
Practice Address - Fax:706-721-1158
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA11877207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program