Provider Demographics
NPI:1174691711
Name:BOWSER, STANLEY CLYDE (OD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:CLYDE
Last Name:BOWSER
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:1725B DUAL HWY
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6653
Practice Address - Country:US
Practice Address - Phone:301-739-6573
Practice Address - Fax:301-739-6577
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOET008772152W00000X
MDTA0981152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410046919OtherRAILROAD MEDICARE
PAB01314766OtherHIGHMARK BLUE SHIELD
PA0018624220001Medicaid
PAB01314766OtherHIGHMARK BLUE SHIELD