Provider Demographics
NPI:1639168529
Name:KOVAL, JOHN M (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:KOVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 UPPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-6819
Mailing Address - Country:US
Mailing Address - Phone:813-633-2733
Mailing Address - Fax:813-642-0367
Practice Address - Street 1:12206 BRUCE B DOWNS BLVD
Practice Address - Street 2:STE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9211
Practice Address - Country:US
Practice Address - Phone:813-971-8276
Practice Address - Fax:813-971-8277
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37669174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045208400Medicaid
FL208700OtherAVMED
FL30746OtherBLUE CROSS BLUE SHIELD
FL300126984OtherRAILROAD MEDICARE
FL15211OtherALL FLORIDA PPO
FL4129443OtherAETNA
FL208700OtherAVMED
FL30746VMedicare ID - Type Unspecified