Provider Demographics
NPI:1356534952
Name:FOWLKES, JASON (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FOWLKES
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 1:1055 GREEN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073
Mailing Address - Country:US
Mailing Address - Phone:540-798-8887
Mailing Address - Fax:
Practice Address - Street 1:809 DAVIS ST
Practice Address - Street 2:STE 1
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7013
Practice Address - Country:US
Practice Address - Phone:540-961-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116016565208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1356534952Medicaid
VA021734M21Medicare PIN