Provider Demographics
NPI:1629195672
Name:ROBERT B. BOWER, O.D., S.C.
Entity Type:Organization
Organization Name:ROBERT B. BOWER, O.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:BOWER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:2626-547-6005
Mailing Address - Street 1:2301 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-1403
Mailing Address - Country:US
Mailing Address - Phone:262-654-6005
Mailing Address - Fax:
Practice Address - Street 1:2301 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-1403
Practice Address - Country:US
Practice Address - Phone:262-654-6005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38525800Medicaid
WIT61546Medicare UPIN
WI000087458Medicare PIN
WI0573700001Medicare NSC