Provider Demographics
NPI:1528133964
Name:FOWLER, MARK DWAYNE II
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DWAYNE
Last Name:FOWLER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 LA SALLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2437
Mailing Address - Country:US
Mailing Address - Phone:909-880-9085
Mailing Address - Fax:
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-3404
Practice Address - Fax:310-223-0621
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator