Healthcare Provider Details

I. General information

NPI: 1619919156
Provider Name (Legal Business Name): LENNON E. BOWEN IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 E LAKE BLVD STE 201
VANCLEAVE MS
39565
US

IV. Provider business mailing address

6300 E LAKE BLVD STE 301
VANCLEAVE MS
39565-6771
US

V. Phone/Fax

Practice location:
  • Phone: 228-230-2663
  • Fax: 228-206-1192
Mailing address:
  • Phone: 228-230-2663
  • Fax: 228-206-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number18586
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number18586
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: