Provider Demographics
NPI:1174504872
Name:KOVALCZYK, WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:KOVALCZYK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0846
Mailing Address - Country:US
Mailing Address - Phone:678-376-5714
Mailing Address - Fax:
Practice Address - Street 1:148 MISSION OAK DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4153
Practice Address - Country:US
Practice Address - Phone:678-376-5714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA684213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00521474AMedicaid
GA48SCBNSMedicare ID - Type Unspecified
GA00521474AMedicaid