Provider Demographics
NPI:1689676298
Name:COVAULT, MICHEAL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:R
Last Name:COVAULT
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 1:7718 E OAKMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-3527
Mailing Address - Country:US
Mailing Address - Phone:316-315-0621
Mailing Address - Fax:316-315-0621
Practice Address - Street 1:1124 WEST 21ST STREET
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002
Practice Address - Country:US
Practice Address - Phone:316-300-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-30920207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200330190AMedicaid
KS104792Medicare ID - Type Unspecified
KS200330190AMedicaid