Provider Demographics
NPI:1104848399
Name:KOVAR, CLEMENT JERRY II (MD)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:JERRY
Last Name:KOVAR
Suffix:II
Gender:M
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:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-396-0851
Practice Address - Street 1:3330 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5002
Practice Address - Country:US
Practice Address - Phone:310-325-9110
Practice Address - Fax:310-784-8762
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25022207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G250220OtherBLUE SHIELD
CA00G250220Medicaid
CAG25022Medicare ID - Type Unspecified
CA00G250220OtherBLUE SHIELD