Healthcare Provider Details

I. General information

NPI: 1386835585
Provider Name (Legal Business Name): JUSTIN FOWLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 W EMERALD ST
BOISE ID
83704-8613
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-3900
  • Fax: 208-302-3955
Mailing address:
  • Phone: 210-916-3174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberM-13069
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberM-13069
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberMD2014-0304
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number2016027259
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberQ6009
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: