Provider Demographics
NPI:1902819162
Name:KOVAN, JEFFREY RICHARD (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RICHARD
Last Name:KOVAN
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 1:4660 S HAGADORN RD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5353
Mailing Address - Country:US
Mailing Address - Phone:517-884-6100
Mailing Address - Fax:
Practice Address - Street 1:4660 S HAGADORN RD STE 420
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5353
Practice Address - Country:US
Practice Address - Phone:517-884-6100
Practice Address - Fax:517-884-6233
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010030207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902819162Medicaid
MI3194525Medicaid
MI1902819162Medicaid
MIC36093010Medicare PIN
MIE68071Medicare UPIN
MI0C36088031Medicare ID - Type Unspecified