Healthcare Provider Details

I. General information

NPI: 1073541827
Provider Name (Legal Business Name): JIMMY DAYLAND BOWEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 DOCTORS PARK
CAPE GIRARDEAU MO
63703-4928
US

IV. Provider business mailing address

48 DOCTORS PARK
CAPE GIRARDEAU MO
63703-4928
US

V. Phone/Fax

Practice location:
  • Phone: 573-388-3045
  • Fax: 573-335-8424
Mailing address:
  • Phone: 573-388-3045
  • Fax: 573-335-8424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2007008844
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: