Healthcare Provider Details

I. General information

NPI: 1639192412
Provider Name (Legal Business Name): MARK RANDALL BOWMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 3RD ST
TILLAMOOK OR
97141-3430
US

IV. Provider business mailing address

4397 GLENVIEW AVE
TILLAMOOK OR
97141-2864
US

V. Phone/Fax

Practice location:
  • Phone: 503-815-2280
  • Fax:
Mailing address:
  • Phone: 503-842-3750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD18668
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD18668
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: