Provider Demographics
NPI:1982639860
Name:FOWLER, GRANT C (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:C
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 301448
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1448
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:713-512-2236
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:250
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:832-325-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8111207Q00000X, 207QG0300X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137012401OtherCSHCN
TX137012405Medicaid
TX88Y812OtherBCBS
TX137012405Medicaid
TX080150517Medicare PIN
TX137012401OtherCSHCN