Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | SC003328R | PA |
NPI | 1316945496 |
---|---|
Provider Name | Kurt Kriztofer Kovalovich |
First Address | Pine Grove, PA 17963-0167 |
Second Address | Pine Grove, PA 17963-1029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2005 |
Last Update Date | 30/11/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T71334 | (02) | PA |