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General NPI Number Information
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NPI Number | 1174153969
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Entity Type | Individual
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Provider Name | JEREN ROBERT KOWALEWSKI PA-C
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Gender | Male
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Dates
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Enumeration Date | 01/21/2020
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Last Update Date | 01/21/2020
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Provider Practice Location Address
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Address Line | 1340 CITIZENS BLVD
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City | LEESBURG
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State | FL
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Zip | 34748-3924
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Country | US
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Telephone | 352-435-7695
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Fax |
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Provider Business Mailing Address
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Address Line | 920 ROLLING ACRES RD UNIT 205
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City | LADY LAKE
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State | FL
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Zip | 32159-5029
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Country | US
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Telephone | 352-633-7930
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Fax | 352-633-7924
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 9112658
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License Number State | FL
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