Provider Demographics
NPI:1366550030
Name:FOWLER, GRACE ELAINE (DO)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ELAINE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:GRACE
Other - Middle Name:ELAINE
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-0030
Mailing Address - Country:US
Mailing Address - Phone:812-882-5524
Mailing Address - Fax:812-882-5525
Practice Address - Street 1:626 PRAIRE STREET
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1060
Practice Address - Country:US
Practice Address - Phone:812-882-5524
Practice Address - Fax:812-882-5525
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003008A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200391740AMedicaid
INH75174Medicare UPIN
IN200391740AMedicaid