1053631259 NPI number — DR. BOWLVA MICHAEL LEE D.O.

Table of content: DR. BOWLVA MICHAEL LEE D.O. (NPI 1053631259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053631259 NPI number — DR. BOWLVA MICHAEL LEE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
BOWLVA
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053631259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 HIGHWAY 377, SUITE 140, PMB 155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76262-6893
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-560-1640
Provider Business Mailing Address Fax Number:
972-972-8660

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9441 LBJ FWY SUITE 114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75243-4635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-557-4111
Provider Business Practice Location Address Fax Number:
972-972-8660
Provider Enumeration Date:
06/10/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  P2477 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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