Provider Demographics
NPI:1689369019
Name:FOWLER, EVAN ALSBURY (DO)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:ALSBURY
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 1:4947 CHAPEL XING
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2689
Mailing Address - Country:US
Mailing Address - Phone:404-863-2894
Mailing Address - Fax:
Practice Address - Street 1:7045 LIGHTHOUSE WAY
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7000
Practice Address - Country:US
Practice Address - Phone:419-794-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.033581390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program