Provider Demographics
NPI:1861486839
Name:GWIN, JOHN L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:GWIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:721 GLENWOOD DR
Mailing Address - Street 2:SUITE 553
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-1106
Mailing Address - Country:US
Mailing Address - Phone:423-495-2640
Mailing Address - Fax:423-495-2644
Practice Address - Street 1:721 GLENWOOD DR
Practice Address - Street 2:SUITE 553
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1106
Practice Address - Country:US
Practice Address - Phone:423-495-2640
Practice Address - Fax:423-495-2644
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD24584174400000X
TN24584208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4088202OtherBLUE CROSS BLUE SHIELD
TN3076991Medicaid
TN3076991Medicaid
TN3076991Medicare PIN