Provider Demographics
NPI:1497715478
Name:MCGOWAN, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MCGOWAN
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:PO BOX 11768
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-0168
Mailing Address - Country:US
Mailing Address - Phone:804-353-4000
Mailing Address - Fax:804-213-9783
Practice Address - Street 1:2621 GROVE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4308
Practice Address - Country:US
Practice Address - Phone:804-254-5467
Practice Address - Fax:804-254-9898
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010397272083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09637OtherMEDICARE GROUP NUMBER
B07828Medicare UPIN
00W589C01Medicare ID - Type Unspecified