Provider Demographics
NPI:1548368749
Name:FOWLER, VINCENT ROY (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:ROY
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 1:9041 MAGNOLIA AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3956
Mailing Address - Country:US
Mailing Address - Phone:951-354-2220
Mailing Address - Fax:951-354-2218
Practice Address - Street 1:9041 MAGNOLIA AVE STE 206
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3956
Practice Address - Country:US
Practice Address - Phone:951-354-2220
Practice Address - Fax:951-354-2218
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30049207N00000X
AZ42759207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A300490Medicaid
AZZ153954Medicare PIN
CAWA30049AMedicare UPIN
AZZ153953Medicare PIN