Provider Demographics
NPI:1669465142
Name:KOVACH, KRISTINA MARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:MARIE
Last Name:KOVACH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639004
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9004
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:15800 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3748
Practice Address - Country:US
Practice Address - Phone:216-227-2194
Practice Address - Fax:216-227-2196
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002928213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2035158Medicaid
OHP00351773OtherRRCARE
OHP00351773OtherRRCARE
OH2035158Medicaid