Provider Demographics
NPI:1376629428
Name:KOVACEVICH, GUY J (MD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:J
Last Name:KOVACEVICH
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:PO BOX 2819
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-2819
Mailing Address - Country:US
Mailing Address - Phone:970-949-5434
Mailing Address - Fax:970-949-0376
Practice Address - Street 1:142 BEAVER CREEK PLACE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:970-949-5434
Practice Address - Fax:970-949-0376
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30110207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C50461OtherPTAN
CO84-1203107OtherEIN
COC50461Medicare PIN
CO50461Medicare ID - Type Unspecified
CO84-1203107OtherEIN