Provider Demographics
NPI:1093987893
Name:FOWLER, BRIAN T (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:FOWLER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 CRESTHAVEN RD STE 300
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0809
Mailing Address - Country:US
Mailing Address - Phone:901-866-8864
Mailing Address - Fax:
Practice Address - Street 1:1068 CRESTHAVEN RD STE 400
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0845
Practice Address - Country:US
Practice Address - Phone:901-448-6650
Practice Address - Fax:901-302-2486
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48454207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181478AMedicaid
AR193108001Medicaid
MS005372219Medicaid
AL182749Medicaid
TN1528624Medicaid
MO1093987893Medicaid