Provider Demographics
NPI:1407160245
Name:THOMAS A. KOWALENKO, D.O.
Entity Type:Organization
Organization Name:THOMAS A. KOWALENKO, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOWALENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-358-8530
Mailing Address - Street 1:808 RARITAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1710
Mailing Address - Country:US
Mailing Address - Phone:732-381-2100
Mailing Address - Fax:732-382-3576
Practice Address - Street 1:808 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1710
Practice Address - Country:US
Practice Address - Phone:732-381-2100
Practice Address - Fax:732-382-3576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MBO6592500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0026808Medicaid
NJ0026808Medicaid
NJ071154Medicare PIN