Provider Demographics
NPI:1235198490
Name:GOWAN, IVAN DARIUS (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DARIUS
Last Name:GOWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-1227
Mailing Address - Country:US
Mailing Address - Phone:315-824-1250
Mailing Address - Fax:
Practice Address - Street 1:85 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-1227
Practice Address - Country:US
Practice Address - Phone:315-824-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153105207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00842957Medicaid
NY00842957Medicaid
AA0495Medicare PIN
NYCC0194Medicare ID - Type Unspecified