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General NPI Number Information
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NPI Number | 1548250103
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Entity Type | Individual
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Provider Name | MARK KOWALSKI WALLACE M.D
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Gender | Male
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Dates
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Enumeration Date | 10/25/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3851 ROGER BROOKE DR FT SAM HOUSTON
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City | SAN ANTONIO
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State | TX
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Zip | 78234
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Country | US
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Telephone | 210-916-0775
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Fax |
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Provider Business Mailing Address
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Address Line | 12443 TECH RIDGE BLVD #712
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City | AUSTIN
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State | TX
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Zip | 78753
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Country | US
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Telephone | 210-818-7958
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Fax |
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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 | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 01053948A
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License Number State | IN
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