MEDICARE: DR. SAMUEL TODD BOWMAN 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	2264	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20126	OTHER	FL	BCBS
2	20126A	OTHER		BCBS

General Provider Information

NPI Number	:	1871532754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL TODD BOWMAN OD

Provider Business Mailing Address
First Line	:	120 A1A N STE 101
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-6626
Country	:	US
Telephone Number	:	904-280-9000
Fax Number	:	904-280-4448

Provider Business Practice Location Address
First Line	:	120 A1A N STE 101
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-6626
Country	:	US
Telephone Number	:	904-280-9000
Fax Number	:	904-280-4448

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

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	03/22/2018

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