Healthcare Provider Details

I. General information

NPI: 1285855239
Provider Name (Legal Business Name): MARK TIMOTHY KOWAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 LATHROP ST STE 202
FAIRBANKS AK
99701-5937
US

IV. Provider business mailing address

1919 LATHROP ST STE 202
FAIRBANKS AK
99701-5937
US

V. Phone/Fax

Practice location:
  • Phone: 907-451-5507
  • Fax: 907-451-5590
Mailing address:
  • Phone: 907-451-5507
  • Fax: 907-451-5590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number7319
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: