Provider Demographics
NPI:1902828049
Name:KOVACH, BRADLEY TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:TODD
Last Name:KOVACH
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 1:801 ANCHOR RODE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-2742
Mailing Address - Country:US
Mailing Address - Phone:239-263-1717
Mailing Address - Fax:239-403-9410
Practice Address - Street 1:801 ANCHOR RODE DR STE 100
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-2742
Practice Address - Country:US
Practice Address - Phone:239-263-1717
Practice Address - Fax:239-403-9410
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006012910207N00000X
FLME98276207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
208189OtherMO-BLUE SHIELD