Provider Demographics
NPI:1124023221
Name:COVALLA, KEITHA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITHA
Middle Name:ANN
Last Name:COVALLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S GLENBURNIE RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5228
Mailing Address - Country:US
Mailing Address - Phone:252-633-6900
Mailing Address - Fax:252-633-6754
Practice Address - Street 1:2001 S GLENBURNIE RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5228
Practice Address - Country:US
Practice Address - Phone:252-633-6900
Practice Address - Fax:252-633-6754
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093HKOtherBCBSNC PIN
NC89093HKMedicaid
NC2468510Medicare PIN
NC410048747Medicare PIN
NCU87855Medicare UPIN