Provider Demographics
NPI:1558473058
Name:BOWMAN, GARY WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WAYNE
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 596
Mailing Address - Street 2:
Mailing Address - City:GREENBRIER
Mailing Address - State:AR
Mailing Address - Zip Code:72058
Mailing Address - Country:US
Mailing Address - Phone:501-679-4030
Mailing Address - Fax:501-679-4037
Practice Address - Street 1:55A S BROADVIEW
Practice Address - Street 2:
Practice Address - City:GREENBRIER
Practice Address - State:AR
Practice Address - Zip Code:72058
Practice Address - Country:US
Practice Address - Phone:501-679-4030
Practice Address - Fax:501-679-4037
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117992003Medicaid
AR710249735OtherFEDERAL TAX ID
AR16194000000OtherQUAL CHOICE ID
ARE78213Medicare UPIN
54249Medicare PIN