Provider Demographics
NPI:1679572820
Name:FOWLER, DANIEL T (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:T
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 1:3400 LEBANON RD # 114
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-1392
Mailing Address - Country:US
Mailing Address - Phone:615-225-4899
Mailing Address - Fax:615-225-6381
Practice Address - Street 1:3400 LEBANON RD # 114
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-1392
Practice Address - Country:US
Practice Address - Phone:615-225-4899
Practice Address - Fax:615-225-6381
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV157262085R0204X
TNMD72872085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0118140000Medicaid
FO0689143Medicare ID - Type Unspecified
WV0118140000Medicaid