Healthcare Provider Details

I. General information

NPI: 1093777856
Provider Name (Legal Business Name): JEFFREY B FOWLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 E ALBENI HWY SUITE 102
PRIEST RIVER ID
83856-0729
US

IV. Provider business mailing address

PO BOX 729
PRIEST RIVER ID
83856-0729
US

V. Phone/Fax

Practice location:
  • Phone: 208-448-2321
  • Fax: 208-448-1317
Mailing address:
  • Phone: 208-448-2321
  • Fax: 208-448-1317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0-49
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: