Provider Demographics
NPI:1013972405
Name:BOWERSOX, DANIEL MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MARK
Last Name:BOWERSOX
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1127
Mailing Address - Country:US
Mailing Address - Phone:502-647-3937
Mailing Address - Fax:502-633-7326
Practice Address - Street 1:403 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1127
Practice Address - Country:US
Practice Address - Phone:502-647-3937
Practice Address - Fax:502-633-7326
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1301DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77013019Medicaid
KY77013019Medicaid
KY0503201Medicare ID - Type Unspecified
KY1021620001Medicare NSC