Healthcare Provider Details

I. General information

NPI: 1578302063
Provider Name (Legal Business Name): MIKAYLA BOWEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/23/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 NW 12TH AVE
MIAMI FL
33136-1003
US

IV. Provider business mailing address

1480 NW NORTH RIVER DR APT 2403
MIAMI FL
33125-2881
US

V. Phone/Fax

Practice location:
  • Phone: 305-325-5511
  • Fax:
Mailing address:
  • Phone: 704-699-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40018
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number40018
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: