Provider Demographics
NPI:1619062064
Name:OWEN, WILLIAM I (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:I
Last Name:OWEN
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 1:4300 WEST MAIN STREET
Mailing Address - Street 2:SUITE 43
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305
Mailing Address - Country:US
Mailing Address - Phone:334-793-7211
Mailing Address - Fax:334-793-5425
Practice Address - Street 1:4300 WEST MAIN STREET
Practice Address - Street 2:SUITE 43
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-793-7211
Practice Address - Fax:334-793-5425
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13944174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000082133Medicaid
AL000082133Medicare ID - Type Unspecified
ALE42073Medicare UPIN