Healthcare Provider Details

I. General information

NPI: 1548250103
Provider Name (Legal Business Name): MARK KOWALSKI WALLACE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR FT SAM HOUSTON
SAN ANTONIO TX
78234
US

IV. Provider business mailing address

12443 TECH RIDGE BLVD #712
AUSTIN TX
78753
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-0775
  • Fax:
Mailing address:
  • Phone: 210-818-7958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number01053948A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: