Healthcare Provider Details

I. General information

NPI: 1043243744
Provider Name (Legal Business Name): MICHELLE BURNSIDE FOWERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 03/31/2022
Certification Date: 03/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W IH 635 FWY SUITE 250
IRVING TX
75063-3718
US

IV. Provider business mailing address

400 W IH 635 FWY SUITE 250
IRVING TX
75063-3718
US

V. Phone/Fax

Practice location:
  • Phone: 972-481-6400
  • Fax: 972-831-9794
Mailing address:
  • Phone: 972-481-6400
  • Fax: 972-831-9794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL3302
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: