Provider Demographics
NPI:1710050273
Name:KOVACS, BONNIE CHRISTINE (OD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:CHRISTINE
Last Name:KOVACS
Suffix:
Gender:F
Credentials:OD
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 30015 DPT 93
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0015
Mailing Address - Country:US
Mailing Address - Phone:307-733-1051
Mailing Address - Fax:307-733-0686
Practice Address - Street 1:555 E BROADWAY AVE STE 214
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-733-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY243T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120435100Medicaid
WY5340400001OtherMEDICARE DMEPOS
WYV07569Medicare UPIN