Provider Demographics
NPI:1760581524
Name:FOWLER, ELMER WILLIAM JR (DO PL)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:WILLIAM
Last Name:FOWLER
Suffix:JR
Gender:M
Credentials:DO PL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3351 CLAYSTONE ST SE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5781
Mailing Address - Country:US
Mailing Address - Phone:616-954-1991
Mailing Address - Fax:616-954-1998
Practice Address - Street 1:3351 CLAYSTONE ST SE
Practice Address - Street 2:SUITE 212
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5781
Practice Address - Country:US
Practice Address - Phone:616-954-1991
Practice Address - Fax:616-954-1998
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010075462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI26221802854050Medicaid
MI26221802854050Medicaid
F537565Medicare UPIN