Provider Demographics
NPI:1255420758
Name:INDOVINA, JOHN ALBERT JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALBERT
Last Name:INDOVINA
Suffix:JR
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 1:15225 HIGHWAY 43 STE B-1
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1999
Mailing Address - Country:US
Mailing Address - Phone:256-332-8658
Mailing Address - Fax:
Practice Address - Street 1:15225 HIGHWAY 43 STE B-1
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1999
Practice Address - Country:US
Practice Address - Phone:256-332-8658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD021449208600000X
ALMD28281208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1987662Medicaid
AL009913354Medicaid
LAF79402Medicare UPIN
LA1987662Medicaid
AL5101020005Medicare PIN
AL009913354Medicaid