Provider Demographics
NPI:1508247024
Name:FOWLER, DUSTIN (DO)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 JEWELL DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6630
Mailing Address - Country:US
Mailing Address - Phone:254-753-1411
Mailing Address - Fax:
Practice Address - Street 1:221 JEWELL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6630
Practice Address - Country:US
Practice Address - Phone:254-753-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL37667207R00000X, 208000000X
TXS1399207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics