Provider Demographics
NPI:1063576429
Name:FOWLER, ELIZABETH MAE (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MAE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:MAE
Other - Last Name:FOWLERSMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 526845
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33152-6845
Mailing Address - Country:US
Mailing Address - Phone:321-434-7191
Mailing Address - Fax:321-434-5295
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-7191
Practice Address - Fax:321-434-5295
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7067820207ZP0102X, 207ZP0102X
FLME151404207ZP0102X
IN01064239A208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program