Healthcare Provider Details

I. General information

NPI: 1568590214
Provider Name (Legal Business Name): JONATHAN EARL BOWLING O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JONATHAN EARL BOWLING

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 SMITH AVE
SHALLOTTE NC
28470-4458
US

IV. Provider business mailing address

PO BOX 867
SHALLOTTE NC
28459-0867
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-2020
  • Fax: 910-754-8811
Mailing address:
  • Phone: 910-754-2020
  • Fax: 910-754-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1177
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: