Provider Demographics
NPI:1356390439
Name:KOWALCZUK, GEORGE G (DO)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:G
Last Name:KOWALCZUK
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:690 CANTON ST
Mailing Address - Street 2:SUITE 325
Mailing Address - City:WESTWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02090-2321
Mailing Address - Country:US
Mailing Address - Phone:781-407-7713
Mailing Address - Fax:781-407-0998
Practice Address - Street 1:690 CANTON ST
Practice Address - Street 2:SUITE 325
Practice Address - City:WESTWOOD
Practice Address - State:MA
Practice Address - Zip Code:02090-2321
Practice Address - Country:US
Practice Address - Phone:781-407-7713
Practice Address - Fax:781-407-0998
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA150212207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110058018AMedicaid
MAJ17300OtherBLUE CROSS/BLUE SHIELD
MA3161293Medicaid
MA150212OtherTUFTS HEALTH PLAN
MA277191OtherHARVARD PILGRIM HEALTHCAR
MA3161293Medicaid
MAA21860Medicare PIN
MA110058018AMedicaid
MAHX5031Medicare PIN