Provider Demographics
NPI:1588891782
Name:FOWLER, STAR VIVIETTE (DO)
Entity type:Individual
Prefix:DR
First Name:STAR
Middle Name:VIVIETTE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11750 W 2ND PL
Mailing Address - Street 2:SUITE 365
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1575
Mailing Address - Country:US
Mailing Address - Phone:720-321-8280
Mailing Address - Fax:720-321-8281
Practice Address - Street 1:11750 W 2ND PL
Practice Address - Street 2:SUITE 365
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1575
Practice Address - Country:US
Practice Address - Phone:720-321-8280
Practice Address - Fax:720-321-8281
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR.0051309207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22230025Medicaid