Basic Information
Provider Information | |||||||||
NPI: | 1518941418 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWERS | ||||||||
FirstName: | JUDITH | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11109 PARKVIEW PLAZA DR # 117 | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2602666013 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1270 E STATE ROAD 205 STE 140 | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA CITY | ||||||||
State: | IN | ||||||||
PostalCode: | 467258505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604256650 | ||||||||
FaxNumber: | 2604256649 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2005 | ||||||||
LastUpdateDate: | 10/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 02001885 | IN | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 200139890 | 05 | IN |   | MEDICAID | 000000775518 | 01 | IN | ANTHEM | OTHER | 7227093 | 01 | IN | AETNA | OTHER |