Provider Demographics
NPI:1104329887
Name:FOWLER, KOBY DOUGLAS (DC)
Entity type:Individual
Prefix:DR
First Name:KOBY
Middle Name:DOUGLAS
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 WEST ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1023
Mailing Address - Country:US
Mailing Address - Phone:860-620-1705
Mailing Address - Fax:860-620-1746
Practice Address - Street 1:1095 WEST ST UNIT 1
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-620-1705
Practice Address - Fax:860-620-1746
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor