Healthcare Provider Details

I. General information

NPI: 1740282797
Provider Name (Legal Business Name): PAUL VICTOR KOWALSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W MORTON AVE
JACKSONVILLE IL
62650-2623
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-7015
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-6814
  • Fax: 217-245-0375
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-3068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number053472
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number200301373
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036079360
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number336042367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: