Provider Demographics
NPI:1295739639
Name:GREEN-MCGOWAN, MARTINA A (MD)
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:A
Last Name:GREEN-MCGOWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:G
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:236 SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4666
Mailing Address - Country:US
Mailing Address - Phone:574-293-0052
Mailing Address - Fax:574-293-3744
Practice Address - Street 1:236 SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516
Practice Address - Country:US
Practice Address - Phone:574-293-0052
Practice Address - Fax:574-293-3744
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01041734207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100357660Medicaid
184520GGGMedicare PIN
IND66939Medicare UPIN