Provider Demographics
NPI:1851301352
Name:KOWYNIA, PETER D (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:KOWYNIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43211 DALCOMA
Mailing Address - Street 2:STE 7
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-286-8800
Mailing Address - Fax:586-286-8068
Practice Address - Street 1:43211 DALCOMA
Practice Address - Street 2:STE 7
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-286-8800
Practice Address - Fax:586-286-8068
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301051240208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
104187OtherGREAT LAKES
2938OtherCAPE
102451OtherCARE CHOICES
MI102873117Medicaid
MI020502600OtherBCBS
C3404OtherMCARE
MI4540079OtherAETNA
MI020502600OtherBCBS
MI0502600Medicare ID - Type Unspecified