Basic Information
| Provider Information | |||||||||
| NPI: | 1932605425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOWALKE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25487 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342772487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9412025342 | ||||||||
| FaxNumber: | 8552534836 | ||||||||
| Practice Location | |||||||||
| Address1: | 7915 US HIGHWAY 301 N STE 107 | ||||||||
| Address2: | |||||||||
| City: | ELLENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342223532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418471101 | ||||||||
| FaxNumber: | 9414172811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 149932 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 21645 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME149932 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.