Provider Demographics
NPI:1457450363
Name:MCGOWAN, EFFIEMARIE (OD)
Entity Type:Individual
Prefix:
First Name:EFFIEMARIE
Middle Name:
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:EFFIEMARIE
Other - Middle Name:HINES
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0838
Practice Address - Street 1:12591 SORRENTO RD
Practice Address - Street 2:SUITE B
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8754
Practice Address - Country:US
Practice Address - Phone:850-497-0711
Practice Address - Fax:850-497-6219
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2293152W00000X
FLOPC3817152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621041400Medicaid
FL36008OtherFLORIDA BLUE
FL36008OtherFLORIDA BLUE
FLU7107XMedicare PIN
FLU7107AMedicare ID - Type UnspecifiedMIL IND #