Provider Demographics
NPI:1548254089
Name:KOWALCZYK, JOHN JAMES (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JAMES
Last Name:KOWALCZYK
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 1:1127 WILSHIRE BLVD STE 805
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-3909
Mailing Address - Country:US
Mailing Address - Phone:213-977-1176
Mailing Address - Fax:213-977-0668
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE 805
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-3901
Practice Address - Country:US
Practice Address - Phone:213-977-1176
Practice Address - Fax:213-977-0668
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6818208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340018768OtherMEDICARE RR
CA00AX68180Medicaid
340018768OtherMEDICARE RR
4158510001Medicare NSC