=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083682785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY D. BOWMAN O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1410 N MARKET ST
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-443-4373
-----------------------------------------------------
Fax | 618-443-2682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1410 N MARKET ST
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-443-4373
-----------------------------------------------------
Fax | 618-443-2682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | TO3081
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------