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General NPI Number Information
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NPI Number | 1407160245
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Entity Type | Organization
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Legal Business Name | THOMAS A. KOWALENKO, D.O.
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Dates
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Enumeration Date | 08/04/2010
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Last Update Date | 08/04/2010
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Provider Practice Location Address
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Address Line | 808 RARITAN RD
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City | CLARK
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State | NJ
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Zip | 07066-1710
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Country | US
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Telephone | 732-381-2100
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Fax | 732-382-3576
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Provider Business Mailing Address
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Address Line | 808 RARITAN RD
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City | CLARK
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State | NJ
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Zip | 07066-1710
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Country | US
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Telephone | 732-381-2100
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Fax | 732-382-3576
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Authorized Official
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Title or Position | OWNER
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Name | DR. THOMAS A KOWALENKO
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Credential | D.O.
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Telephone | 908-358-8530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25MBO6592500
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License Number State | NJ
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