Provider Demographics
NPI:1538136429
Name:KOWALENKO, THOMAS A (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:KOWALENKO
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 1:808 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06592500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0026808Medicaid
NJ071154Medicare ID - Type Unspecified
NJ0026808Medicaid