Provider Demographics
NPI:1740282797
Name:KOWALSKI, PAUL VICTOR (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:VICTOR
Last Name:KOWALSKI
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 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7015
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-3068
Practice Address - Street 1:2000 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2623
Practice Address - Country:US
Practice Address - Phone:217-245-6814
Practice Address - Fax:217-245-0375
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053472207W00000X
NC200301373207W00000X
IL036079360207W00000X
IL336042367207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141F1OtherBCBS PROV #
33079OtherOPTICARE PROVIDER NUMBER
P00395184OtherRR MEDICARE PROV. NUMBER
NC5902639Medicaid
NC807073OtherPARTNERS PROV NUMBER
NC807073OtherPARTNERS PROV NUMBER
NC2049281DMedicare ID - Type Unspecified
NC2049281EMedicare ID - Type Unspecified
NC5902639Medicaid
NC2049281HMedicare PIN
P00395184OtherRR MEDICARE PROV. NUMBER
NC2049281FMedicare ID - Type Unspecified
NC2049281CMedicare ID - Type Unspecified
NC141F1OtherBCBS PROV #
NC2049281AMedicare ID - Type Unspecified
E01389Medicare UPIN