Provider Demographics
NPI:1811992647
Name:OWEN, CLARENCE H (MD)
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:H
Last Name:OWEN
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 1:270 S MOON AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5711
Mailing Address - Country:US
Mailing Address - Phone:813-571-9988
Mailing Address - Fax:813-571-9922
Practice Address - Street 1:270 S MOON AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5711
Practice Address - Country:US
Practice Address - Phone:813-571-9988
Practice Address - Fax:813-571-9922
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME157851208G00000X
NC33925208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC780001235OtherRR MCR
NC1807389OtherUHC
NC1136EOtherBCBS
NC891136EMedicaid
NC80107OtherMEDCOST
NC80107OtherMEDCOST
NC891136EMedicaid