Healthcare Provider Details

I. General information

NPI: 1902047533
Provider Name (Legal Business Name): FREDERICK FOWLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 HIGHWAY 104
IONE CA
95640
US

IV. Provider business mailing address

214 ASHWORTH DR
IONE CA
95640-5436
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-4911
  • Fax:
Mailing address:
  • Phone: 209-274-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberA21296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: