Basic Information
| Provider Information | |||||||||
| NPI: | 1336299098 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 545 E REDD RD | ||||||||
| Address2: | SUITE C2 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799121293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152981008 | ||||||||
| FaxNumber: | 9152981009 | ||||||||
| Practice Location | |||||||||
| Address1: | 545 E REDD RD | ||||||||
| Address2: | SUITE C-2 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799121293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152981008 | ||||||||
| FaxNumber: | 9152981009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M6539 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3100802-02 | 05 | TX | MEDICAID |