Provider Demographics
NPI:1588660633
Name:BOWEN, BRYAN R (OD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:R
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 1:1200 W DEYOUNG ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-4437
Mailing Address - Country:US
Mailing Address - Phone:618-993-5686
Mailing Address - Fax:618-997-6250
Practice Address - Street 1:401 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:PINCKNEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62274-1344
Practice Address - Country:US
Practice Address - Phone:618-357-2020
Practice Address - Fax:618-357-2100
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001018120152W00000X
IL046009730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009730Medicaid
IL046009730Medicaid