=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548254089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN JAMES KOWALCZYK DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2005
-----------------------------------------------------
Last Update Date | 11/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 WILSHIRE BLVD SUITE 805
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-977-1176
-----------------------------------------------------
Fax | 213-977-0668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 WILSHIRE BLVD STE 805
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-977-1176
-----------------------------------------------------
Fax | 213-977-0668
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 20A6818
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------