Provider Demographics
NPI:1558462499
Name:KOWALSKE, KEITH EDWARD (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:KOWALSKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N DRIES LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-1259
Mailing Address - Country:US
Mailing Address - Phone:309-688-6644
Mailing Address - Fax:309-688-6670
Practice Address - Street 1:3100 N DRIES LN
Practice Address - Street 2:SUITE 101
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-1259
Practice Address - Country:US
Practice Address - Phone:309-688-6644
Practice Address - Fax:309-688-6670
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0918690001OtherDMERC
IL0918690001OtherDMERC
ILT39240Medicare UPIN