Healthcare Provider Details

I. General information

NPI: 1780644054
Provider Name (Legal Business Name): BRENT J BOWEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 250 E STE 235
MURRAY UT
84107-6191
US

IV. Provider business mailing address

5810 S 300 E # 300
MURRAY UT
84107-6178
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-5115
  • Fax: 801-314-5112
Mailing address:
  • Phone: 801-314-2346
  • Fax: 801-314-2345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number94-273603-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: