Healthcare Provider Details

I. General information

NPI: 1144369869
Provider Name (Legal Business Name): CAROL E. KOWTONIUK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 FAIRFIELD AVE
JOHNSTOWN PA
15906-2310
US

IV. Provider business mailing address

226 FAIRFIELD AVE
JOHNSTOWN PA
15906-2310
US

V. Phone/Fax

Practice location:
  • Phone: 814-535-6167
  • Fax: 814-535-5428
Mailing address:
  • Phone: 814-535-6167
  • Fax: 814-535-5428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS004976L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: