Provider Demographics
NPI:1124003892
Name:KOVALCHIK, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:KOVALCHIK
Suffix:
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 1:780 LITCHFIELD ST
Mailing Address - Street 2:SUITE200
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6268
Mailing Address - Country:US
Mailing Address - Phone:860-489-1984
Mailing Address - Fax:860-496-2195
Practice Address - Street 1:780 LITCHFIELD ST
Practice Address - Street 2:SUITE200
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6268
Practice Address - Country:US
Practice Address - Phone:860-489-1984
Practice Address - Fax:860-496-2195
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020094207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
010020094CT01OtherANTHEM
539143OtherAETNA
P3600333OtherOXFORD
00120094800OtherANTHEM FAMILY
CT1200948Medicaid
752466OtherCONNECTICARE
040477OtherHEALTH NET
390000030Medicare ID - Type Unspecified
CT1200948Medicaid