Provider Demographics
NPI:1265532881
Name:FOWLER, KEITH (CSA)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:CSA
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 361972
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30036-1972
Mailing Address - Country:US
Mailing Address - Phone:404-803-0110
Mailing Address - Fax:
Practice Address - Street 1:3717 MEADOW VISTA TRL
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-7736
Practice Address - Country:US
Practice Address - Phone:404-803-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist