Provider Demographics
NPI:1154327674
Name:OWEN, PHILIP SELWYN (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:SELWYN
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 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MEDICAL STAFF OFFICE
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 PABLO ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3818
Practice Address - Country:US
Practice Address - Phone:863-284-5941
Practice Address - Fax:863-284-5199
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062977207RC0000X
FLME62977207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18039WMedicare PIN
FLF39297Medicare UPIN
FL371362800Medicaid