Provider Demographics
NPI:1134398746
Name:FOWLER, NICOLE MCCORMICK (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MCCORMICK
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:CATHERINE
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-844-5460
Mailing Address - Fax:216-201-5157
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-5460
Practice Address - Fax:216-201-5157
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60358087207Y00000X
OH35.123544207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105336Medicaid
WA1134398746Medicaid
WA1134398746Medicaid
OH0105336Medicaid