Provider Demographics
NPI:1891788014
Name:BOWEN, MITCHEAL BLANE (DO)
Entity Type:Individual
Prefix:DR
First Name:MITCHEAL
Middle Name:BLANE
Last Name:BOWEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-5405
Mailing Address - Country:US
Mailing Address - Phone:256-766-3062
Mailing Address - Fax:256-767-1804
Practice Address - Street 1:409 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5405
Practice Address - Country:US
Practice Address - Phone:256-766-3062
Practice Address - Fax:256-767-1804
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0516936Medicaid
D89766Medicare UPIN
OH0516936Medicaid