=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154312007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY MILTON COWAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2005
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 9TH AVENUE #404
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-332-1782
-----------------------------------------------------
Fax | 817-336-8619
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 9TH AVENUE #404
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-332-1782
-----------------------------------------------------
Fax | 817-336-8619
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207WX0107X
-----------------------------------------------------
Taxonomy Name | Retina Specialist (Ophthalmology) Physician
-----------------------------------------------------
License Number | F6544
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------