Provider Demographics
NPI:1548200116
Name:FOWLER, MARIECKEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIECKEN
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 1:11215 METRO PKWY BLDG 3
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1206
Mailing Address - Country:US
Mailing Address - Phone:239-208-2212
Mailing Address - Fax:
Practice Address - Street 1:11215 METRO PKWY STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1206
Practice Address - Country:US
Practice Address - Phone:239-208-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012382782084B0040X, 2084D0003X, 2084N0400X
MO20200356402084N0400X
PAMD4735972084N0400X
NH206372084N0400X
FLME1463372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2084D0003XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyDiagnostic Neuroimaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA196654OtherANTHEM BCBS
VAP00349159OtherRAILROAD MEDICARE
VA010214851Medicaid
VA001854467OtherMOUNTAIN STATE BCBS
VA001854467OtherMOUNTAIN STATE BCBS