Provider Demographics
NPI:1629157680
Name:MCGOWAN, DONALD D (DPM)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:D
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 MISHAWAKA AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2347
Mailing Address - Country:US
Mailing Address - Phone:574-288-8200
Mailing Address - Fax:574-288-8226
Practice Address - Street 1:3015 MISHAWAKA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2347
Practice Address - Country:US
Practice Address - Phone:574-288-8200
Practice Address - Fax:574-288-8226
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000684213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1629157680OtherNPI
IN000000088330OtherANTHEM
IN100091280AMedicaid
IN1932389244OtherNPI
INM300056628OtherPTAN
IN100091280AMedicaid
T36901Medicare UPIN
165630AMedicare ID - Type Unspecified
INM300056628OtherPTAN