MEDICARE: DR. BRYAN R BOWEN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2001018120	MO
2	152W00000X	Optometrist	046009730	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588660633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN R BOWEN OD

Provider Business Mailing Address
First Line	:	1200 W DEYOUNG ST
Second Line	:
City	:	MARION
State	:	IL
Zip	:	62959-4437
Country	:	US
Telephone Number	:	618-993-5686
Fax Number	:	618-997-6250

Provider Business Practice Location Address
First Line	:	401 S WALNUT ST
Second Line	:
City	:	PINCKNEYVILLE
State	:	IL
Zip	:	62274-1344
Country	:	US
Telephone Number	:	618-357-2020
Fax Number	:	618-357-2100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	01/25/2017

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