Provider Demographics
NPI:1043201338
Name:KOVACH, CASSONDRA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:CASSONDRA
Middle Name:LYNN
Last Name:KOVACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4131 MERIDIAN DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:WI
Practice Address - Zip Code:53598-9699
Practice Address - Country:US
Practice Address - Phone:608-846-3741
Practice Address - Fax:608-846-7898
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56450-20207Q00000X, 207Q00000X
MI4301083274207Q00000X
MICK083274207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICK083274OtherSTATE LICENSE #
P00160742OtherRAILROAD MEDICARE
MI31354OtherHEALTH PLAN OF MI
MI0800311522OtherBCBS MI PROV #
WI1043201338Medicaid
MI4615612Medicaid
2397259OtherUNITED HEALTHCARE
MIP31738FOtherBLUE CARE NETWORK
01-30787OtherPHP PROV #
MICK083274OtherSTATE LICENSE #
WI1043201338Medicaid
2397259OtherUNITED HEALTHCARE