Provider Demographics
NPI:1457342818
Name:FOWERS, GARY K (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:K
Last Name:FOWERS
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 1:1325 N 600 E
Mailing Address - Street 2:STE 102
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2684
Mailing Address - Country:US
Mailing Address - Phone:435-753-9999
Mailing Address - Fax:435-753-0546
Practice Address - Street 1:1325 N 600 E
Practice Address - Street 2:STE 102
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2684
Practice Address - Country:US
Practice Address - Phone:435-753-9999
Practice Address - Fax:435-753-0546
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3584731205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870643195001Medicaid
UT870643195001Medicaid