Provider Demographics
NPI:1356311286
Name:KOVALCIK, PAUL JEROME (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JEROME
Last Name:KOVALCIK
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 1:3105 AMERICAN LEGION ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5653
Mailing Address - Country:US
Mailing Address - Phone:757-686-2687
Mailing Address - Fax:757-484-1682
Practice Address - Street 1:3105 AMERICAN LEGION ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5653
Practice Address - Country:US
Practice Address - Phone:757-686-2687
Practice Address - Fax:757-484-1682
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032355208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5834961Medicaid
A54207Medicare UPIN