Healthcare Provider Details

I. General information

NPI: 1396182705
Provider Name (Legal Business Name): JOHN W FOWLER JR. MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 COLONIAL RD
MEMPHIS TN
38117-3206
US

IV. Provider business mailing address

PO BOX 770175
MEMPHIS TN
38177-0175
US

V. Phone/Fax

Practice location:
  • Phone: 901-844-2500
  • Fax:
Mailing address:
  • Phone: 901-844-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD011043
License Number StateTN

VIII. Authorized Official

Name: JOHN W FOWLER
Title or Position: SOLE MEMBER
Credential: MD
Phone: 901-844-2500