Provider Demographics
NPI:1417261744
Name:KOVAC, KYLIN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KYLIN
Middle Name:
Last Name:KOVAC
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 ELK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8322
Mailing Address - Country:US
Mailing Address - Phone:208-529-8393
Mailing Address - Fax:208-529-8398
Practice Address - Street 1:1540 ELK CREEK DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8322
Practice Address - Country:US
Practice Address - Phone:208-529-8393
Practice Address - Fax:208-529-8398
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002356213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6787710001Medicare NSC