Provider Demographics
NPI:1366402588
Name:KOWALSKI, MARK A (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:165 POPLAR ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462-1235
Mailing Address - Country:US
Mailing Address - Phone:207-723-3003
Mailing Address - Fax:207-723-3006
Practice Address - Street 1:165 POPLAR ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462-1235
Practice Address - Country:US
Practice Address - Phone:207-723-3003
Practice Address - Fax:207-723-3006
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016015208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME022326OtherANTHEM
4203395OtherAETNA US HEALTHCARE
F10120OtherHARVARD PILGRAM HEALTHCAR
F10120Medicare UPIN
ME022326OtherANTHEM
MI200003Medicare ID - Type Unspecified