Provider Demographics
NPI:1942296066
Name:KOWALKOWSKI, THOMAS S (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:KOWALKOWSKI
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 1:176 DAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9302
Mailing Address - Country:US
Mailing Address - Phone:304-647-4411
Mailing Address - Fax:304-647-5708
Practice Address - Street 1:1521 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8026
Practice Address - Country:US
Practice Address - Phone:304-647-5642
Practice Address - Fax:304-647-5708
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14532208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0040599000Medicaid
WV0619251Medicare ID - Type Unspecified
WV0040599000Medicaid