Basic Information
| Provider Information | |||||||||
| NPI: | 1457450363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOWAN | ||||||||
| FirstName: | EFFIEMARIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MCGOWAN | ||||||||
| OtherFirstName: | EFFIEMARIE | ||||||||
| OtherMiddleName: | HINES | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15933 CLAYTON RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630112172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270838 | ||||||||
| Practice Location | |||||||||
| Address1: | 12591 SORRENTO RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325078754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504970711 | ||||||||
| FaxNumber: | 8504976219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 08/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2293 | MD | N | Eye and Vision Services Providers | Optometrist | 152W00000X | OPC3817 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 621041400 | 05 | FL | MEDICAID | 36008 | 01 | FL | FLORIDA BLUE | OTHER |