Provider Demographics
NPI:1477554657
Name:MCEWEN, GARY W (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:MCEWEN
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 1:276 NE TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:LEE'S SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5696
Mailing Address - Country:US
Mailing Address - Phone:816-525-8500
Mailing Address - Fax:816-525-0185
Practice Address - Street 1:276 NE TUDOR RD
Practice Address - Street 2:
Practice Address - City:LEE'S SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5696
Practice Address - Country:US
Practice Address - Phone:816-525-8500
Practice Address - Fax:816-525-0185
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9N60207N00000X
MOR9N30207NS0135X, 207ND0101X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00412861OtherRAILROAD PTAN
MOX028279Medicare PIN
MOP00412861OtherRAILROAD PTAN