Basic Information
| Provider Information | |||||||||
| NPI: | 1174691711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWSER | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | CLYDE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725B DUAL HWY | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217406653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017396573 | ||||||||
| FaxNumber: | 3017396577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OET008772 | PA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | TA0981 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 410046919 | 01 | RAILROAD MEDICARE | OTHER | B01314766 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0018624220001 | 05 | PA | MEDICAID |