Provider Demographics
NPI:1639192412
Name:BOWMAN, MARK RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RANDALL
Last Name:BOWMAN
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 1:4397 GLENVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2864
Mailing Address - Country:US
Mailing Address - Phone:503-842-3750
Mailing Address - Fax:
Practice Address - Street 1:1000 3RD ST
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3430
Practice Address - Country:US
Practice Address - Phone:503-815-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18668208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR93ZGBGZW2Medicare UPIN
ORF49980Medicare ID - Type Unspecified