Provider Demographics
NPI:1093742090
Name:KAWALICK, MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:KAWALICK
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 1:3 PHEASANT HL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1629
Mailing Address - Country:US
Mailing Address - Phone:860-674-1213
Mailing Address - Fax:
Practice Address - Street 1:35 PEARL ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-2644
Practice Address - Country:US
Practice Address - Phone:860-223-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT220792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001220797Medicaid
CT001220797Medicaid
CT130000121Medicare ID - Type Unspecified