Provider Demographics
NPI:1619919156
Name:BOWEN, LENNON E IV (MD)
Entity Type:Individual
Prefix:
First Name:LENNON
Middle Name:E
Last Name:BOWEN
Suffix:IV
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 1:6300 E LAKE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6771
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:6300 E LAKE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:228-206-1192
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS185862084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
646000515OtherCOMMERCIAL
P00280787OtherRAILROAD MEDICARE
MS02277207Medicaid
646000515OtherCOMMERCIAL
$$$$$$$$$OtherTRICARE
MS130000266Medicare ID - Type Unspecified
$$$$$$$$$COtherBLUE CROSS AND BLUE SHIELD