Healthcare Provider Details

I. General information

NPI: 1841419595
Provider Name (Legal Business Name): THEODORE A. BOWLES JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/17/2024
Certification Date: 08/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100183
GAINESVILLE FL
32610-0183
US

V. Phone/Fax

Practice location:
  • Phone: 478-737-6605
  • Fax:
Mailing address:
  • Phone: 352-392-0140
  • Fax: 352-392-8217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS18091
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: