Provider Demographics
NPI:1780769182
Name:BOWMAN, MARK C (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:BOWMAN
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 1:2451 SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7815
Mailing Address - Country:US
Mailing Address - Phone:707-526-4050
Mailing Address - Fax:707-569-1366
Practice Address - Street 1:2451 SUMMERFIELD RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7815
Practice Address - Country:US
Practice Address - Phone:707-526-4050
Practice Address - Fax:707-569-1366
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07746T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0077460Medicaid
CA0304490001Medicare NSC
CASD0077460Medicare PIN
CASD0077460Medicaid
CA410007347Medicare PIN