Provider Demographics
NPI:1104992585
Name:COWAN, GERALD A (OD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:A
Last Name:COWAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 SW 8TH CT
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2902
Mailing Address - Country:US
Mailing Address - Phone:239-677-8998
Mailing Address - Fax:
Practice Address - Street 1:301 SW PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33991-2043
Practice Address - Country:US
Practice Address - Phone:239-800-6032
Practice Address - Fax:239-574-9038
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4121152W00000X
MO2010037748152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1104992585Medicaid
FLP00369126OtherRAIL ROAD MEDICARE
MO1104992585Medicaid
FLAA188ZMedicare PIN