Provider Demographics
NPI:1114980083
Name:OWEN, RALPH GLEN (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:GLEN
Last Name:OWEN
Suffix:
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 1:1710 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5733
Mailing Address - Country:US
Mailing Address - Phone:706-733-8202
Mailing Address - Fax:706-736-7806
Practice Address - Street 1:1710 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5733
Practice Address - Country:US
Practice Address - Phone:706-733-8202
Practice Address - Fax:706-736-7806
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist