Healthcare Provider Details

I. General information

NPI: 1811169550
Provider Name (Legal Business Name): JEFFREY ALAN KOWALSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 N WISCONSIN ST
ELKHORN WI
53121-4541
US

IV. Provider business mailing address

839 N WISCONSIN ST
ELKHORN WI
53121-4541
US

V. Phone/Fax

Practice location:
  • Phone: 262-741-1400
  • Fax: 262-741-1401
Mailing address:
  • Phone: 262-741-1400
  • Fax: 262-741-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54448-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA117482
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: