Healthcare Provider Details

I. General information

NPI: 1457801441
Provider Name (Legal Business Name): IAN JOSEPH KOWALSKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 05/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6816 GRIFFIN RD
DAVIE FL
33314-4341
US

IV. Provider business mailing address

453 SW 169TH TER
WESTON FL
33326-1530
US

V. Phone/Fax

Practice location:
  • Phone: 786-864-0425
  • Fax:
Mailing address:
  • Phone: 954-300-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberOS14568
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License NumberOS14568
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: