Healthcare Provider Details

I. General information

NPI: 1255693156
Provider Name (Legal Business Name): MATTHEW CALLIS FOWLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 BAYOU BLVD
PENSACOLA FL
32503-2601
US

IV. Provider business mailing address

4451 BAYOU BLVD
PENSACOLA FL
32503-2601
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7619
  • Fax: 850-416-7753
Mailing address:
  • Phone: 850-416-7619
  • Fax: 850-416-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberUO3013
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS12439
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: