Provider Demographics
NPI:1053472027
Name:KOWALCZYK, CAROLE L (MD)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:L
Last Name:KOWALCZYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 E. 13 MILE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-576-0431
Mailing Address - Fax:586-576-0924
Practice Address - Street 1:4700 E. 13 MILE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-576-0431
Practice Address - Fax:586-576-0924
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK 054864207VE0102X
MI4301054864207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F64872Medicare UPIN