Provider Demographics
NPI:1457028250
Name:KOVACH, BRADLEY (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:KOVACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 FROOM RANCH WAY
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-7211
Mailing Address - Country:US
Mailing Address - Phone:805-544-0450
Mailing Address - Fax:
Practice Address - Street 1:1540 FROOM RANCH WAY
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-7211
Practice Address - Country:US
Practice Address - Phone:805-544-0450
Practice Address - Fax:805-544-0275
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34935152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist