Provider Demographics
NPI:1366830648
Name:GOWAN, JIMMY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:LEE
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 1:513 S SWEETWATER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-9550
Mailing Address - Country:US
Mailing Address - Phone:864-486-8379
Mailing Address - Fax:
Practice Address - Street 1:513 S SWEETWATER HILLS DR
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:SC
Practice Address - Zip Code:29369-9550
Practice Address - Country:US
Practice Address - Phone:864-486-8379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC 4935208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice