Healthcare Provider Details

I. General information

NPI: 1396005310
Provider Name (Legal Business Name): JEFFREY MICHAEL KOWALESKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

VA BOSTON HEALTHCARE 940 BELMONT ST
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 774-826-1860
  • Fax:
Mailing address:
  • Phone: 774-826-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD459066
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number63698-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: