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General NPI Number Information
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NPI Number | 1386835585
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Entity Type | Individual
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Provider Name | JUSTIN FOWLER MD
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Gender | Male
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 6165 W EMERALD ST
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City | BOISE
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State | ID
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Zip | 83704-8613
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Country | US
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Telephone | 208-302-3900
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Fax | 208-302-3955
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Provider Business Mailing Address
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Address Line | 3551 ROGER BROOKE DR
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234-4504
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Country | US
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Telephone | 210-916-3174
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | M-13069
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 2086S0102X
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Taxonomy Name | Surgical Critical Care Physician
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License Number | M-13069
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | MD2014-0304
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License Number State | NM
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Taxonomy #4
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | 2016027259
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License Number State | MO
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Taxonomy #5
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | Q6009
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License Number State | TX
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Taxonomy #6
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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