Provider Demographics
NPI:1730443771
Name:BOWEN, BRADLEY N (OD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:N
Last Name:BOWEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 HARDEES DR
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-7062
Mailing Address - Country:US
Mailing Address - Phone:570-538-6002
Mailing Address - Fax:
Practice Address - Street 1:1172 STATE ROUTE 487
Practice Address - Street 2:
Practice Address - City:PAXINOS
Practice Address - State:PA
Practice Address - Zip Code:17860-7570
Practice Address - Country:US
Practice Address - Phone:866-995-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002649152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102747277Medicaid