Individual
DR. SUSAN M FOWELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1235 N MULFORD RD, SUITE 100, ROCKFORD, IL 61107-3879
(815) 226-4990
(815) 226-9472
Mailing address
1235 N MULFORD RD, SUITE 100, ROCKFORD, IL 61107-3879
(815) 226-4990
(815) 226-9472
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
036073359
IL
207WX0107X
Retina Specialist (Ophthalmology) Physician
Primary
036073359
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036073359
IL STATE LICENSE #
IL
05
—
036073359
—
IL
01
—
363734974
TAX ID#
IL
Enumeration date
05/23/2005
Last updated
07/06/2017
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