1437721917 NPI number — DR. JACQUELINE SOLANGE KOWAL OD

Table of content: DR. JACQUELINE SOLANGE KOWAL OD (NPI 1437721917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437721917 NPI number — DR. JACQUELINE SOLANGE KOWAL OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOWAL
Provider First Name:
JACQUELINE
Provider Middle Name:
SOLANGE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437721917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 W SOUTHERN AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85210-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-961-1865
Provider Business Mailing Address Fax Number:
480-893-8172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 E CAMELBACK RD STE 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-3947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-277-3348
Provider Business Practice Location Address Fax Number:
602-264-2715
Provider Enumeration Date:
07/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0003684 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OPT-002627 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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