Healthcare Provider Details

I. General information

NPI: 1083093272
Provider Name (Legal Business Name): TIMOTHY B KOWALESKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 BEACON ST
FORT WAYNE IN
46805-4749
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-8000
  • Fax: 260-373-8034
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02004981A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number02004981A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: