Provider Demographics
NPI:1215950431
Name:BOWEN, DIANE GWYN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:GWYN
Last Name:BOWEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 ARTHUR J MOORE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2206
Mailing Address - Country:US
Mailing Address - Phone:912-634-1993
Mailing Address - Fax:
Practice Address - Street 1:1015 ARTHUR J MOORE DR
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2206
Practice Address - Country:US
Practice Address - Phone:912-634-1993
Practice Address - Fax:912-634-1166
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA313862086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11340888OtherCAQH NUMBER
GA11340888OtherCAQH NUMBER