Provider Demographics
NPI:1487605259
Name:OWENS, BRUCE ALLEN (DO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:OWENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 N LOOP 289
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3025
Mailing Address - Country:US
Mailing Address - Phone:806-788-0040
Mailing Address - Fax:
Practice Address - Street 1:4642 N LOOP 289
Practice Address - Street 2:STE 215
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-2409
Practice Address - Country:US
Practice Address - Phone:806-721-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4518207R00000X
MO2010024532207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1487605259Medicaid
KS201126820AMedicaid
NM41392Medicaid
MO1487605259Medicaid
MOP01628484OtherMEDICARE RAILROAD
MOP01628484OtherMEDICARE RAILROAD
TX45-5232942OtherTIN
NM41392Medicaid