Provider Demographics
NPI:1790758506
Name:FOWLER, BLAINE ALSIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:ALSIN
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 1:8701 CUYAMACA ST
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071
Mailing Address - Country:US
Mailing Address - Phone:619-568-8025
Mailing Address - Fax:619-568-8095
Practice Address - Street 1:8071 CUYAMACA ST
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071
Practice Address - Country:US
Practice Address - Phone:619-568-8025
Practice Address - Fax:619-568-8095
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36915ZMedicaid
CAW629Medicare ID - Type Unspecified
CAZZZ36915ZMedicaid