Provider Demographics
NPI:1912031154
Name:MOWERY, TOM HARVEY (CPO, LPO)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:HARVEY
Last Name:MOWERY
Suffix:
Gender:M
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 W INDIAN RIVER BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-3500
Mailing Address - Country:US
Mailing Address - Phone:386-409-9432
Mailing Address - Fax:386-409-9433
Practice Address - Street 1:602 W INDIAN RIVER BLVD STE 4
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-3500
Practice Address - Country:US
Practice Address - Phone:386-409-9432
Practice Address - Fax:386-409-9433
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR 162222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5427620001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER