Provider Demographics
NPI:1770118655
Name:DERRICK BOWLING MD PA
Entity type:Organization
Organization Name:DERRICK BOWLING MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-388-8863
Mailing Address - Street 1:308 NE 22ND ST
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1115
Mailing Address - Country:US
Mailing Address - Phone:205-388-8863
Mailing Address - Fax:
Practice Address - Street 1:3516 NE 12TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-4524
Practice Address - Country:US
Practice Address - Phone:954-459-5487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty