Healthcare Provider Details

I. General information

NPI: 1861486839
Provider Name (Legal Business Name): JOHN L GWIN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 03/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 GLENWOOD DR SUITE 553
CHATTANOOGA TN
37404-1106
US

IV. Provider business mailing address

721 GLENWOOD DR SUITE 553
CHATTANOOGA TN
37404-1106
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-2640
  • Fax: 423-495-2644
Mailing address:
  • Phone: 423-495-2640
  • Fax: 423-495-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD24584
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number24584
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: