Provider Demographics
NPI:1922206143
Name:FOWLER, JEREMY R (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4663 SCOTTS VALLEY DR
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-4202
Practice Address - Country:US
Practice Address - Phone:831-458-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC158759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine