Provider Demographics
NPI:1013071885
Name:BOVA, CHARLES MIKELL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MIKELL
Last Name:BOVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3065 OAK RIM LN
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-6804
Mailing Address - Country:US
Mailing Address - Phone:435-655-8648
Mailing Address - Fax:
Practice Address - Street 1:3336 PIONEER PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2000
Practice Address - Country:US
Practice Address - Phone:801-964-3249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1856992081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD43054Medicare UPIN