Provider Demographics
NPI:1457801441
Name:KOWALSKI, IAN JOSEPH (DO)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:JOSEPH
Last Name:KOWALSKI
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 1:453 SW 169TH TER
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1530
Mailing Address - Country:US
Mailing Address - Phone:954-300-7688
Mailing Address - Fax:
Practice Address - Street 1:6816 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-4341
Practice Address - Country:US
Practice Address - Phone:786-864-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2019-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14568208VP0000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty