Provider Demographics
NPI:1598736209
Name:BOWEN, MARK THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
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:ALEXANDRIA VAHCS
Mailing Address - Street 2:2495 SHREVEPORT HWY
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:
Practice Address - Street 1:ALEXANDRIA VAHCS
Practice Address - Street 2:2495 SHREVEPORT HWY
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA932-143T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1370886Medicaid
LA48344Medicare ID - Type Unspecified
LA1370886Medicaid