Provider Demographics
NPI:1154386886
Name:FOWLER, TODD A (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:A
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 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-952-2111
Mailing Address - Fax:423-282-1657
Practice Address - Street 1:161 HEART DR STE B
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-433-6390
Practice Address - Fax:423-433-6391
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24265207Q00000X, 207QS0010X
VA0101270439207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3075096Medicaid
TN1300680001Medicare NSC
TN3075098Medicare PIN
F01837Medicare UPIN