Provider Demographics
NPI:1669470530
Name:MCGOVERN, MICHAEL JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:MCGOVERN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 HAWKINS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2324
Mailing Address - Country:US
Mailing Address - Phone:631-588-5100
Mailing Address - Fax:631-588-5185
Practice Address - Street 1:624 HAWKINS AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2324
Practice Address - Country:US
Practice Address - Phone:631-588-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV5891152W00000X
TNOD2344152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01870373Medicaid
NY01870373Medicaid
NYC3911C07771Medicare PIN