1154379022 NPI number — DR. ELIZABETH J GOWER MD

Table of content: DR. ELIZABETH J GOWER MD (NPI 1154379022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154379022 NPI number — DR. ELIZABETH J GOWER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOWER
Provider First Name:
ELIZABETH
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154379022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 LYNNWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23452-6017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-306-8940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 CONSTITUTION DR
Provider Second Line Business Practice Location Address:
SUITE 217
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23462-6799
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-499-7442
Provider Business Practice Location Address Fax Number:
757-490-3638
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101047362 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105552 . This is a "ANTHEM BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36465 . This is a "OPTIMA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1154379022 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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