Provider Demographics
NPI:1699791947
Name:MOLLMAN, BOWEN MICHAEL (OD)
Entity type:Individual
Prefix:
First Name:BOWEN
Middle Name:MICHAEL
Last Name:MOLLMAN
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 1:2005 ELM ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-2128
Mailing Address - Country:US
Mailing Address - Phone:605-351-1363
Mailing Address - Fax:
Practice Address - Street 1:3001 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-4890
Practice Address - Country:US
Practice Address - Phone:605-665-4600
Practice Address - Fax:605-665-4813
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDT615152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203540Medicaid
SD551483OtherPROV. # FOR NVA
SD29963OtherPROV. # FOR SPECTERA
SD10025365000Medicaid
SD0100821OtherWELLMARK BC/BS
SD10025365000Medicaid
SDV08091Medicare UPIN