Provider Demographics
NPI:1215079892
Name:TKB FOWLER DO INC
Entity type:Organization
Organization Name:TKB FOWLER DO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:KB
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-522-2891
Mailing Address - Street 1:6189 LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2858
Mailing Address - Country:US
Mailing Address - Phone:714-522-2891
Mailing Address - Fax:714-522-8176
Practice Address - Street 1:6189 LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-2858
Practice Address - Country:US
Practice Address - Phone:714-522-2891
Practice Address - Fax:714-522-8176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00AX78810207Q00000X
CA20A7881207Q00000X
CA20A7613207Q00000X
CAA43569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16003Medicare ID - Type Unspecified
W16003Medicare UPIN