Provider Demographics
NPI:1104808070
Name:FOWLER, RAYMOND D (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:D
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40914 CRESTED CRANE ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-9465
Mailing Address - Country:US
Mailing Address - Phone:907-235-9440
Mailing Address - Fax:
Practice Address - Street 1:4300 BARTLETT ST
Practice Address - Street 2:SOUTH PENISULA HOSPITAL
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7005
Practice Address - Country:US
Practice Address - Phone:907-235-8101
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4624207L00000X
WY6970A207L00000X
AZ30104207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD46242Medicaid
AKMD46242Medicaid
AK152101Medicare ID - Type Unspecified