Provider Demographics
NPI:1962463828
Name:FOWLER, DANIEL W III (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:FOWLER
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S LAREDO AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-4853
Mailing Address - Country:US
Mailing Address - Phone:479-567-5555
Mailing Address - Fax:501-889-5555
Practice Address - Street 1:109 S LAREDO AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-567-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1271111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR141551718Medicaid
AR5T626Medicare ID - Type Unspecified
U31598Medicare UPIN