Provider Demographics
NPI:1922577568
Name:KOVACIC, COURTNEY A (PA)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:A
Last Name:KOVACIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:STEFANIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8205 MAIN ST STE 14
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6054
Mailing Address - Country:US
Mailing Address - Phone:716-539-0789
Mailing Address - Fax:716-250-9090
Practice Address - Street 1:8643 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6315
Practice Address - Country:US
Practice Address - Phone:716-565-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05492168Medicaid