Provider Demographics
NPI:1649407883
Name:KOVACIK, ANGELA HERRO (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:HERRO
Last Name:KOVACIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18325 N ALLIED WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-3105
Mailing Address - Country:US
Mailing Address - Phone:602-467-4966
Mailing Address - Fax:480-419-5401
Practice Address - Street 1:18325 N ALLIED WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054
Practice Address - Country:US
Practice Address - Phone:602-467-4966
Practice Address - Fax:480-419-5401
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR71499207R00000X
FLME115266207W00000X
AZ47164207WX0109X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ17888Medicaid