Provider Demographics
NPI:1649277211
Name:KOWALCZYK, MICHAEL CASMIR (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CASMIR
Last Name:KOWALCZYK
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 PATIENT CARE DR STE A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-4271
Mailing Address - Country:US
Mailing Address - Phone:517-374-7600
Mailing Address - Fax:885-480-9150
Practice Address - Street 1:3955 PATIENT CARE DR STE A
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4271
Practice Address - Country:US
Practice Address - Phone:517-374-7600
Practice Address - Fax:885-480-9150
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2025-03-18
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MIMK010436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901730-11Medicaid
MI0C36084003Medicare PIN
MI2901730-11Medicaid