Provider Demographics
NPI:1477545630
Name:BOVA, KENNETH A (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:BOVA
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 1:54 LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-4127
Mailing Address - Country:US
Mailing Address - Phone:724-439-4870
Mailing Address - Fax:724-439-4871
Practice Address - Street 1:54 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-4127
Practice Address - Country:US
Practice Address - Phone:724-439-4870
Practice Address - Fax:724-439-4871
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000534152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA289011Medicare PIN
PA0208190001Medicare NSC