Provider Demographics
NPI:1982645586
Name:FOWLER, JUSTIN ALLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ALLEN
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 HUFFMAN MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-8700
Mailing Address - Country:US
Mailing Address - Phone:336-538-1234
Mailing Address - Fax:336-584-6811
Practice Address - Street 1:1234 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-1234
Practice Address - Fax:336-538-2390
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC462213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908090Medicaid
NC2433673Medicare ID - Type Unspecified
NC8908090Medicaid