Healthcare Provider Details

I. General information

NPI: 1538136429
Provider Name (Legal Business Name): THOMAS A KOWALENKO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 RARITAN RD
CLARK NJ
07066-1710
US

IV. Provider business mailing address

808 RARITAN RD
CLARK NJ
07066-1710
US

V. Phone/Fax

Practice location:
  • Phone: 732-381-2100
  • Fax: 732-382-3576
Mailing address:
  • Phone: 732-381-2100
  • Fax: 732-382-3576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB06592500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: