Provider Demographics
NPI:1649538505
Name:FOWLE, EVAN (DO)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:FOWLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14275 MIDWAY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:225 NE 97TH ST STE 600
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6302
Practice Address - Country:US
Practice Address - Phone:405-842-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6290207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program