Provider Demographics
NPI:1477812394
Name:KOVANDA, TIMOTHY JAMES
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:KOVANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N SENATE BLVD
Mailing Address - Street 2:SUITE 535
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1228
Mailing Address - Country:US
Mailing Address - Phone:317-396-1234
Mailing Address - Fax:
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 490
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2773
Practice Address - Country:US
Practice Address - Phone:763-427-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-12
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN63385207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program