Healthcare Provider Details

I. General information

NPI: 1023196037
Provider Name (Legal Business Name): THERA ANN BOWEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 CHERRY ST
MILFORD CT
06460-3502
US

IV. Provider business mailing address

202 CHERRY ST
MILFORD CT
06460-3502
US

V. Phone/Fax

Practice location:
  • Phone: 203-878-1236
  • Fax: 203-876-5196
Mailing address:
  • Phone: 203-878-1236
  • Fax: 203-876-5196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002261
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: