Basic Information
| Provider Information | |||||||||
| NPI: | 1548365778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWERS | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 N GRAND AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856211061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202811550 | ||||||||
| FaxNumber: | 5202811112 | ||||||||
| Practice Location | |||||||||
| Address1: | 1852 N MASTICK WAY | ||||||||
| Address2: | |||||||||
| City: | NOGALES | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856211063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202811550 | ||||||||
| FaxNumber: | 5202811112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 21710 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 21710 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 65244 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3063949 | 05 | TN | MEDICAID | 102970 | 05 | AZ | MEDICAID | 4105065 | 01 | TN | BLUE CROSS | OTHER |