Provider Demographics
NPI:1821048901
Name:KOVAC, ROMAN (DO)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:KOVAC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6200 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-8608
Practice Address - Country:US
Practice Address - Phone:614-566-0602
Practice Address - Fax:614-566-0581
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005525K207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000315472OtherBCBS
P0014928OtherRAIL ROAD MEDICARE
OH0884799Medicaid
OH000000315472OtherBCBS
KO4116362Medicare PIN