1548262710 NPI number — JEFFREY L MCGOWEN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548262710 NPI number — JEFFREY L MCGOWEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCGOWEN
Provider First Name:
JEFFREY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1548262710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 HARRIS PKWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76132-4249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-877-3432
Provider Business Mailing Address Fax Number:
817-346-4394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6301 HARRIS PKWY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76132-4249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-877-3432
Provider Business Practice Location Address Fax Number:
817-346-4394
Provider Enumeration Date:
06/01/2005

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: 207XS0114X , with the licence number:  L8833 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 181787603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8P6302 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: L8833 . This is a "STATE LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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