Provider Demographics
NPI:1396808275
Name:BOWMAN, KENNETH LEE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 SALIDO AVE
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159
Mailing Address - Country:US
Mailing Address - Phone:715-635-0165
Mailing Address - Fax:844-395-8871
Practice Address - Street 1:1150 SALIDO AVE
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:715-610-7401
Practice Address - Fax:844-395-8871
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1467192085B0100X
WI43368-202085B0100X
WI433682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34136600Medicaid
WIF24855Medicare UPIN
WI0080Medicare ID - Type Unspecified