Provider Demographics
NPI:1700078441
Name:FOWLER, MARCIA ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:ELIZABETH
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15660 SAN CARLOS BLVD.
Mailing Address - Street 2:UNIT # 294
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2889
Mailing Address - Country:US
Mailing Address - Phone:239-338-8069
Mailing Address - Fax:239-433-1626
Practice Address - Street 1:15660 SAN CARLOS BLVD
Practice Address - Street 2:UNIT # 294
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2526
Practice Address - Country:US
Practice Address - Phone:239-338-8069
Practice Address - Fax:239-433-1626
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7283207ZP0102X, 2084B0002X, 2084P0800X
FLOS 7283208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No2084B0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyObesity Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000445200Medicaid
FL000445200Medicaid
FLA11723Medicare UPIN