Provider Demographics
NPI:1174518229
Name:MCGOWAN, BLAKE WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:WILLIAM
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:W.
Other - Middle Name:BLAKE
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE 808
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-660-4484
Mailing Address - Fax:501-660-4490
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE 808
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-660-4484
Practice Address - Fax:501-660-4490
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR01-01185OtherUNITED HEALTHCARE
AR04080013400OtherQUALCHOICE
P00168487OtherRALROAD MEDICARE
AR01-01185OtherUNITED HEALTHCARE
H75203Medicare UPIN