Provider Demographics
NPI:1801822978
Name:MCGOWAN, DIANE L (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:MCGOWAN
Suffix:
Gender:F
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:CLARK-HOLDER CLINIC, P.A.
Mailing Address - Street 2:303 SMITH STREET
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240
Mailing Address - Country:US
Mailing Address - Phone:706-882-8831
Mailing Address - Fax:706-812-4091
Practice Address - Street 1:CLARK-HOLDER CLINIC, P.A.
Practice Address - Street 2:303 SMITH STREET
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240
Practice Address - Country:US
Practice Address - Phone:706-882-8831
Practice Address - Fax:706-812-4091
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29049207Y00000X, 207YX0905X
GA29040207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Not Answered207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Not Answered207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E19913Medicare UPIN
GA04BDBBNMedicare ID - Type Unspecified