Provider Demographics
NPI:1386835585
Name:FOWLER, JUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-3174
Mailing Address - Fax:
Practice Address - Street 1:6165 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8613
Practice Address - Country:US
Practice Address - Phone:208-302-3900
Practice Address - Fax:208-302-3955
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13069207XX0801X, 2086S0102X
NMMD2014-0304207XX0801X
MO2016027259207XX0801X
TXQ6009207XX0801X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2016027259OtherMO LICENSE
TX1L5640OtherMEDICARE
TXP02601779OtherMCRR
TX390382503Medicaid