Provider Demographics
NPI:1548608391
Name:KWOLEK, KEVIN MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MATTHEW
Last Name:KWOLEK
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 1:10247 OTTER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-8868
Mailing Address - Country:US
Mailing Address - Phone:517-404-0117
Mailing Address - Fax:
Practice Address - Street 1:5450 FORT ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4601
Practice Address - Country:US
Practice Address - Phone:734-671-3297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-13
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302012207R00000X
MI5101020646207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine