Healthcare Provider Details

I. General information

NPI: 1720058480
Provider Name (Legal Business Name): RICHARD M. KOWALSKI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LINGLESTOWN RD
HARRISBURG PA
17112-1071
US

IV. Provider business mailing address

111 TRILLIUM DR
PALMYRA PA
17078-9006
US

V. Phone/Fax

Practice location:
  • Phone: 717-657-2020
  • Fax: 717-657-2071
Mailing address:
  • Phone: 717-657-2020
  • Fax: 717-657-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG000119
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: