Provider Demographics
NPI:1144215682
Name:KOVALCHICK, CHARLES J (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:KOVALCHICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:300 W KING ST
Mailing Address - Street 2:
Mailing Address - City:LITTLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17340-1446
Mailing Address - Country:US
Mailing Address - Phone:717-359-9214
Mailing Address - Fax:717-359-8120
Practice Address - Street 1:543 EASTON TPKE
Practice Address - Street 2:
Practice Address - City:LAKE ARIEL
Practice Address - State:PA
Practice Address - Zip Code:18436-4718
Practice Address - Country:US
Practice Address - Phone:570-689-9965
Practice Address - Fax:570-689-0387
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS009495L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001675582Medicaid
PA001675582Medicaid
G87059Medicare UPIN