Provider Demographics
NPI:1740220896
Name:FOWLER, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:FOWLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2730-B PROSPERITY AVENUE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2238
Mailing Address - Country:US
Mailing Address - Phone:703-289-1400
Mailing Address - Fax:703-289-1414
Practice Address - Street 1:3300 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22042-3307
Practice Address - Country:US
Practice Address - Phone:703-289-1400
Practice Address - Fax:703-289-1414
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
VA01012310472080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6718183Medicaid
VA6718205Medicaid
VA6718191Medicaid