Provider Demographics
NPI:1508844945
Name:KOWALCZYK, TIMOTHY JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:KOWALCZYK
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 1:220 BESSEMER RD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-9122
Mailing Address - Country:US
Mailing Address - Phone:724-547-2000
Mailing Address - Fax:724-547-0727
Practice Address - Street 1:220 BESSEMER RD
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666-9122
Practice Address - Country:US
Practice Address - Phone:724-547-2000
Practice Address - Fax:724-547-0727
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002607-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001051102Medicaid
PA130421Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAT29395Medicare UPIN
PA5424530001Medicare NSC