Provider Demographics
NPI:1104818749
Name:BOWMAN, JOHNNY L (OD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:L
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 313
Mailing Address - Street 2:
Mailing Address - City:PURDY
Mailing Address - State:MO
Mailing Address - Zip Code:65734-0313
Mailing Address - Country:US
Mailing Address - Phone:417-442-3020
Mailing Address - Fax:417-442-0101
Practice Address - Street 1:200 WASHINGTON ST STE E
Practice Address - Street 2:
Practice Address - City:PURDY
Practice Address - State:MO
Practice Address - Zip Code:65734-8105
Practice Address - Country:US
Practice Address - Phone:417-442-3020
Practice Address - Fax:417-442-3020
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115015722Medicaid
AR115015722Medicaid
AR0828960001Medicare NSC
ART69346Medicare UPIN