Provider Demographics
NPI:1962477679
Name:BOWEN, LISA MICHELLE (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:BOWEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3617 DAYTON XENIA RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2828
Mailing Address - Country:US
Mailing Address - Phone:937-429-1795
Mailing Address - Fax:
Practice Address - Street 1:3617 DAYTON XENIA RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2828
Practice Address - Country:US
Practice Address - Phone:937-429-1795
Practice Address - Fax:937-429-5354
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT006443152W00000X
PAOEG001257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101012152-0001Medicaid
PA101012152-0001Medicaid
PA073406Medicare ID - Type Unspecified