Provider Demographics
NPI:1417069295
Name:KOVEN, STEPHANIE C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:C
Last Name:KOVEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 W 3RD ST
Mailing Address - Street 2:SUITE 295W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:SUITE 295W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-385-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86188207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA86188AMedicare ID - Type Unspecified
CAWA86188DMedicare ID - Type Unspecified
CAWA86188CMedicare ID - Type Unspecified
CAWA86188BMedicare ID - Type Unspecified