Provider Demographics
NPI:1033163944
Name:KOWALAK, THOMAS M (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:KOWALAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2193
Mailing Address - Country:US
Mailing Address - Phone:716-775-9247
Mailing Address - Fax:716-775-9247
Practice Address - Street 1:3669 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1732
Practice Address - Country:US
Practice Address - Phone:716-688-2154
Practice Address - Fax:716-204-4501
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180089207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01222559Medicaid
NY01222559Medicaid