Provider Demographics
NPI:1750455507
Name:KOWALL, MARK GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:GERARD
Last Name:KOWALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9787
Mailing Address - Country:US
Mailing Address - Phone:805-434-0999
Mailing Address - Fax:805-434-5267
Practice Address - Street 1:78 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9787
Practice Address - Country:US
Practice Address - Phone:805-434-0999
Practice Address - Fax:805-434-5267
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74354207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF36352Medicare UPIN