Provider Demographics
NPI:1184647752
Name:KOWALZYK, DANIEL R (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:KOWALZYK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W NORTH AVE
Mailing Address - Street 2:102
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2135
Mailing Address - Country:US
Mailing Address - Phone:800-732-1066
Mailing Address - Fax:630-941-4333
Practice Address - Street 1:12935 S. GREGORY ST.
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406
Practice Address - Country:US
Practice Address - Phone:708-597-2000
Practice Address - Fax:708-824-4494
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL79175Medicare ID - Type Unspecified