Provider Demographics
NPI:1093048019
Name:KOVOOR, JERRY M (MBBS, MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:KOVOOR
Suffix:
Gender:M
Credentials:MBBS, MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1007
Practice Address - Country:US
Practice Address - Phone:319-353-7123
Practice Address - Fax:319-356-2220
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IASP1962085N0700X
IN01077141A2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201383550Medicaid
IN959090042OtherMEDICARE PTAN