Provider Demographics
NPI:1144294570
Name:FOWLER, ROGER N (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:N
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:3202 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-7727
Practice Address - Country:US
Practice Address - Phone:903-882-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136252713Medicaid
TX752616977028OtherTRICARE
TX136252712Medicaid
TX138737515Medicaid
TX8S3318OtherBCBS OF TEXAS
TX136252704Medicaid
TX75-2616977-066OtherTRICARE
TX136252713Medicaid
TX160032495Medicare PIN
TX752616977028OtherTRICARE
TX8G0869Medicare ID - Type Unspecified
TX136252712Medicaid