Provider Demographics
NPI:1790862555
Name:MCGOWAN, MARK LEROY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEROY
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 FAUNCE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1263
Mailing Address - Country:US
Mailing Address - Phone:508-999-4045
Mailing Address - Fax:508-999-4810
Practice Address - Street 1:145 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1263
Practice Address - Country:US
Practice Address - Phone:508-999-4045
Practice Address - Fax:508-999-4810
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY36124Medicare ID - Type Unspecified