Provider Demographics
NPI:1508397050
Name:FOWLER, BENJAMIN JAMES (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JAMES
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1315 EBERHARDT CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 LOWELL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2792
Practice Address - Country:US
Practice Address - Phone:207-774-8277
Practice Address - Fax:207-871-1415
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI75332-20207W00000X
MDMD26618207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology