Provider Demographics
NPI:1548365778
Name:BOWERS, MARVIN A III (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:A
Last Name:BOWERS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-281-1550
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1852 N MASTICK WAY
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-1063
Practice Address - Country:US
Practice Address - Phone:520-281-1550
Practice Address - Fax:520-281-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21710207Q00000X, 208M00000X
AZ65244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3063949Medicaid
AZ102970Medicaid
TN4105065OtherBLUE CROSS
TN3063949Medicaid