Healthcare Provider Details

I. General information

NPI: 1215950431
Provider Name (Legal Business Name): DIANE GWYN BOWEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 ARTHUR J MOORE DR
SAINT SIMONS ISLAND GA
31522-2206
US

IV. Provider business mailing address

1015 ARTHUR J MOORE DR
SAINT SIMONS ISLAND GA
31522-2206
US

V. Phone/Fax

Practice location:
  • Phone: 912-634-1993
  • Fax: 912-634-1166
Mailing address:
  • Phone: 912-634-1993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number31386
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: