Provider Demographics
NPI:1831170026
Name:GOWEN, MICHAEL PATRICK SR (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PATRICK
Last Name:GOWEN
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:1870 RESERVOIR ST
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-8742
Practice Address - Country:US
Practice Address - Phone:540-434-6622
Practice Address - Fax:540-434-4187
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000690152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1831170026Medicaid
VAC08561Medicare PIN
VA1831170026Medicaid