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General NPI Number Information
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NPI Number | 1669470530
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Entity Type | Individual
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Provider Name | MICHAEL JAMES MCGOVERN O.D.
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Gender | Male
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Dates
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Enumeration Date | 07/13/2005
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Last Update Date | 05/13/2008
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Provider Practice Location Address
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Address Line | 624 HAWKINS AVE SUITE #1
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City | LAKE RONKONKOMA
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State | NY
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Zip | 11779-2324
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Country | US
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Telephone | 631-588-5100
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Fax |
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Provider Business Mailing Address
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Address Line | 624 HAWKINS AVE SUITE 1
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City | LAKE RONKONKOMA
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State | NY
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Zip | 11779-2324
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Country | US
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Telephone | 631-588-5100
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Fax | 631-588-5185
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TUV5891
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OD2344
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License Number State | TN
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