Provider Demographics
NPI:1528370574
Name:BOWEN, NICHOLAS C (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:C
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 1:110 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:61470-9419
Mailing Address - Country:US
Mailing Address - Phone:309-333-5619
Mailing Address - Fax:
Practice Address - Street 1:309 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-2123
Practice Address - Country:US
Practice Address - Phone:262-763-0117
Practice Address - Fax:262-763-0119
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3423-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist