Healthcare Provider Details

I. General information

NPI: 1215614565
Provider Name (Legal Business Name): JOHN MICHAEL FOWLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S EAGLE RD
MERIDIAN ID
83642-6351
US

IV. Provider business mailing address

3080 E GENTRY WAY STE 210
MERIDIAN ID
83642-3013
US

V. Phone/Fax

Practice location:
  • Phone: 208-706-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number3871592
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: