Provider Demographics
NPI:1275621153
Name:BOWERMAN, DOUGLAS W (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:BOWERMAN
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 1:2 COULTER ROAD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-1122
Mailing Address - Country:US
Mailing Address - Phone:315-462-9561
Mailing Address - Fax:315-462-5504
Practice Address - Street 1:2 COULTER ROAD
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432
Practice Address - Country:US
Practice Address - Phone:315-462-9561
Practice Address - Fax:315-462-5504
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221124207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02168014Medicaid
R83537Medicare PIN
H43957Medicare UPIN