Basic Information
| Provider Information | |||||||||
| NPI: | 1356358329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOWALESKI | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | COREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 MILVIA ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045600 | ||||||||
| FaxNumber: | 5102045462 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 MILVIA ST | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947042636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102045600 | ||||||||
| FaxNumber: | 5102045462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G40827 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000G408270 | 01 | CA | BS | OTHER | 00G408270 | 05 | CA | MEDICAID |