Healthcare Provider Details

I. General information

NPI: 1942296066
Provider Name (Legal Business Name): THOMAS S KOWALKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 MAPLEWOOD AVE
RONCEVERTE WV
24970-8026
US

IV. Provider business mailing address

176 DAWKINS DR
LEWISBURG WV
24901-9302
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-5642
  • Fax: 304-647-5708
Mailing address:
  • Phone: 304-647-4411
  • Fax: 304-647-5708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number14532
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: