1811992647 NPI number — CLARENCE H OWEN MD

Table of content: CLARENCE H OWEN MD (NPI 1811992647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811992647 NPI number — CLARENCE H OWEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OWEN
Provider First Name:
CLARENCE
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1811992647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
270 S MOON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-5711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-571-9988
Provider Business Mailing Address Fax Number:
813-571-9922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 S MOON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-571-9988
Provider Business Practice Location Address Fax Number:
813-571-9922
Provider Enumeration Date:
06/17/2005

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: 208G00000X , with the licence number:  ME157851 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208G00000X , with the licence number: 33925 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 780001235 . This is a "RR MCR" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1807389 . This is a "UHC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1136E . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 891136E , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80107 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 115475900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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