Provider Demographics
NPI:1548250103
Name:WALLACE, MARK KOWALSKI (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:KOWALSKI
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12443 TECH RIDGE BLVD
Mailing Address - Street 2:#712
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753
Mailing Address - Country:US
Mailing Address - Phone:210-818-7958
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:FT SAM HOUSTON
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-916-0775
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01053948A207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism