Provider Demographics
NPI:1437598869
Name:FOWLER, JON KEITH II (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:KEITH
Last Name:FOWLER
Suffix:II
Gender:M
Credentials:DO
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Mailing Address - Street 1:2450 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5076
Mailing Address - Country:US
Mailing Address - Phone:575-521-5385
Mailing Address - Fax:915-742-3238
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:WBAMC DEPARTMENT OF MEDICINE GME
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-742-2180
Practice Address - Fax:915-742-3238
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2021-10-05
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Provider Licenses
StateLicense IDTaxonomies
390200000X
NMR-179-2021390200000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program