Provider Demographics
NPI:1265631550
Name:KOVACICH, DIANA L (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:KOVACICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:L
Other - Last Name:SANDNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1275 SADLER WAY STE 202
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3175
Mailing Address - Country:US
Mailing Address - Phone:907-452-4101
Mailing Address - Fax:
Practice Address - Street 1:1275 SADLER WAY STE 202
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3175
Practice Address - Country:US
Practice Address - Phone:907-452-4101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12483207L00000X
WAMD60178246207L00000X
NY258939-1207L00000X
AK7070207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology