Basic Information
| Provider Information | |||||||||
| NPI: | 1548254089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOWALCZYK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | JAMES | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1127 WILSHIRE BLVD STE 805 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900173909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139771176 | ||||||||
| FaxNumber: | 2139770668 | ||||||||
| Practice Location | |||||||||
| Address1: | 1127 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 805 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900173901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139771176 | ||||||||
| FaxNumber: | 2139770668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 20A6818 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00AX68180 | 05 | CA | MEDICAID | 340018768 | 01 | MEDICARE RR | OTHER |