Provider Demographics
NPI:1891736617
Name:BOWMAR, ANDREA (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:BOWMAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1421 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4201
Practice Address - Country:US
Practice Address - Phone:269-684-1330
Practice Address - Fax:269-684-3353
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004472152W00000X
IN18002528152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100341250Medicaid
IN164240JMedicare ID - Type Unspecified