Provider Demographics
NPI:1891784377
Name:COWAN, MICHAEL R (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:COWAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 SOUTH FWY STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-1407
Mailing Address - Country:US
Mailing Address - Phone:817-750-7334
Mailing Address - Fax:817-910-6120
Practice Address - Street 1:4200 SOUTH FWY STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1407
Practice Address - Country:US
Practice Address - Phone:817-750-7334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9459207P00000X, 207PP0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137166812Medicaid
TX8F0304Medicare PIN
TX137166812Medicaid