Provider Demographics
NPI:1770677502
Name:FOWLER, ROBERT DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DOUGLAS
Last Name:FOWLER
Suffix:
Gender:M
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-422-0213
Mailing Address - Fax:
Practice Address - Street 1:145 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3019
Practice Address - Country:US
Practice Address - Phone:731-422-0213
Practice Address - Fax:731-422-0297
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63528207Y00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0645OtherGROUP PIN #
TNQ072228Medicaid