MEDICARE: EFFIEMARIE MCGOWAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TA2293	MD
2	152W00000X	Optometrist	OPC3817	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	36008	OTHER	FL	FLORIDA BLUE

General Provider Information

NPI Number	:	1457450363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EFFIEMARIE MCGOWAN O.D.

Provider Business Mailing Address
First Line	:	15933 CLAYTON RD
Second Line	:	SUITE 201
City	:	BALLWIN
State	:	MO
Zip	:	63011-2172
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0838

Provider Business Practice Location Address
First Line	:	12591 SORRENTO RD
Second Line	:	SUITE B
City	:	PENSACOLA
State	:	FL
Zip	:	32507-8754
Country	:	US
Telephone Number	:	850-497-0711
Fax Number	:	850-497-6219

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	08/04/2017

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