Healthcare Provider Details

I. General information

NPI: 1174153969
Provider Name (Legal Business Name): JEREN ROBERT KOWALEWSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 CITIZENS BLVD
LEESBURG FL
34748-3924
US

IV. Provider business mailing address

920 ROLLING ACRES RD UNIT 205
LADY LAKE FL
32159-5029
US

V. Phone/Fax

Practice location:
  • Phone: 352-435-7695
  • Fax:
Mailing address:
  • Phone: 352-633-7930
  • Fax: 352-633-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number9112658
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: