Provider Demographics
NPI:1568593689
Name:KOVACH, PETER ELLIOT (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ELLIOT
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 1:8050 SANTA TERESA BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3862
Mailing Address - Country:US
Mailing Address - Phone:408-842-2020
Mailing Address - Fax:408-842-0312
Practice Address - Street 1:8050 SANTA TERESA BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3862
Practice Address - Country:US
Practice Address - Phone:408-842-2020
Practice Address - Fax:408-842-0312
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8766152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770531092OtherTAX I.D.
4113270001OtherDME PTAN
4113270001OtherDME PTAN
CASD0087660Medicare ID - Type Unspecified