Provider Demographics
NPI:1679856439
Name:KONOWALCHUK, THOMAS WILLIAM (MD, JD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WILLIAM
Last Name:KONOWALCHUK
Suffix:
Gender:M
Credentials:MD, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 NE 7TH DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-2518
Mailing Address - Country:US
Mailing Address - Phone:541-265-3804
Mailing Address - Fax:
Practice Address - Street 1:1070 NE 7TH DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-2518
Practice Address - Country:US
Practice Address - Phone:541-265-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15049208800000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty