Provider Demographics
NPI:1871532754
Name:BOWMAN, SAMUEL TODD (OD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:TODD
Last Name:BOWMAN
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 1:120 A1A N STE 101
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6626
Mailing Address - Country:US
Mailing Address - Phone:904-280-9000
Mailing Address - Fax:904-280-4448
Practice Address - Street 1:120 A1A N STE 101
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6626
Practice Address - Country:US
Practice Address - Phone:904-280-9000
Practice Address - Fax:904-280-4448
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20126OtherBCBS
20126AOtherBCBS
FL410040101Medicare PIN
20126AOtherBCBS
FL6183330001Medicare NSC
FL20125XMedicare PIN
FL6183330002Medicare NSC