Provider Demographics
NPI:1023196037
Name:BOWEN, THERA ANN (OD)
Entity Type:Individual
Prefix:
First Name:THERA
Middle Name:ANN
Last Name:BOWEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3502
Mailing Address - Country:US
Mailing Address - Phone:203-878-1236
Mailing Address - Fax:203-876-5196
Practice Address - Street 1:202 CHERRY ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3502
Practice Address - Country:US
Practice Address - Phone:203-878-1236
Practice Address - Fax:203-876-5196
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002261152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004195063 GR#Medicaid
CT4123535Medicaid
CT004195063 GR#Medicaid
CT410000732Medicare ID - Type Unspecified