Healthcare Provider Details

I. General information

NPI: 1205243078
Provider Name (Legal Business Name): DR. AGNIESZKA KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 LONGWOOD AVE
BOSTON MA
02115-5728
US

IV. Provider business mailing address

319 LONGWOOD AVE
BOSTON MA
02115-5728
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-3501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125065742
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number270843
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: