Provider Demographics
NPI:1780712901
Name:KOWALCZYK, NICHOLAS DONALD (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DONALD
Last Name:KOWALCZYK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 W CHANDLER BLVD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:480-963-3221
Mailing Address - Fax:480-821-8424
Practice Address - Street 1:2160 W CHANDLER BLVD
Practice Address - Street 2:SUITE 19
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-963-3221
Practice Address - Fax:480-821-8424
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ128152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist