Provider Demographics
NPI:1144535949
Name:DR. MACIEJ Z. KOWALSKI, O.D. INC.
Entity type:Organization
Organization Name:DR. MACIEJ Z. KOWALSKI, O.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MACIEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KOWALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:951-551-6531
Mailing Address - Street 1:28656 BAR HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-2520
Mailing Address - Country:US
Mailing Address - Phone:951-551-6531
Mailing Address - Fax:
Practice Address - Street 1:26672 MARGARITA RD
Practice Address - Street 2:SUITE 305
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-2011
Practice Address - Country:US
Practice Address - Phone:951-894-1515
Practice Address - Fax:951-894-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12596T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ63477YOtherBLUE SHIELD OF CALIFORNIA
CABG336AMedicare PIN