Provider Demographics
NPI:1639425986
Name:KOWALCZYK, KATHIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHIE
Middle Name:
Last Name:KOWALCZYK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 FRIST BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4800
Mailing Address - Country:US
Mailing Address - Phone:772-595-5302
Mailing Address - Fax:
Practice Address - Street 1:2401 FRIST BLVD STE 4
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4800
Practice Address - Country:US
Practice Address - Phone:772-595-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1221572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIC713ZMedicare PIN