Provider Demographics
NPI:1831139419
Name:MOWERY, MARLENE B (OD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:B
Last Name:MOWERY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1650 WOODVALE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2547
Mailing Address - Country:US
Mailing Address - Phone:304-343-4371
Mailing Address - Fax:304-343-0215
Practice Address - Street 1:1306 KANAWHA BLVD E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3001
Practice Address - Country:US
Practice Address - Phone:304-343-4371
Practice Address - Fax:304-343-0215
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV8200D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149311000Medicaid
WV0149311000Medicaid
WV0600804Medicare PIN