Provider Demographics
NPI:1881857993
Name:FOWLER, STEPHEN DERRICK (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:DERRICK
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2042 EASTLAKE AVE E
Mailing Address - Street 2:UNIT C
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3594
Mailing Address - Country:US
Mailing Address - Phone:502-296-8921
Mailing Address - Fax:502-296-8921
Practice Address - Street 1:2042 EASTLAKE AVE E
Practice Address - Street 2:UNIT C
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3594
Practice Address - Country:US
Practice Address - Phone:502-296-8921
Practice Address - Fax:502-296-8921
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA60147300207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0309214Medicaid
PA102756338Medicaid
PA102756338Medicaid