Provider Demographics
NPI:1972643336
Name:KOWTONIUK, WALTER V (DO)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:V
Last Name:KOWTONIUK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15906
Mailing Address - Country:US
Mailing Address - Phone:814-535-6167
Mailing Address - Fax:814-535-5428
Practice Address - Street 1:226 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15906
Practice Address - Country:US
Practice Address - Phone:814-535-6167
Practice Address - Fax:814-535-5428
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004977L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOS004997LMedicaid
PAOS004997LMedicaid
PAB42165Medicare UPIN