Provider Demographics
NPI:1588215933
Name:DR TED KOVACEV MD PA
Entity Type:Organization
Organization Name:DR TED KOVACEV MD PA
Other - Org Name:TED KOVACEV MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:KOVACEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-721-7007
Mailing Address - Street 1:104 CIRCLE WAY ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5200
Mailing Address - Country:US
Mailing Address - Phone:979-721-7007
Mailing Address - Fax:979-721-4254
Practice Address - Street 1:104 CIRCLE WAY ST STE A
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5200
Practice Address - Country:US
Practice Address - Phone:979-721-7007
Practice Address - Fax:979-721-4254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-26
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4042707-01Medicaid