Healthcare Provider Details

I. General information

NPI: 1417261744
Provider Name (Legal Business Name): KYLIN KOVAC D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 WOODKING DR
IDAHO FALLS ID
83404-4736
US

IV. Provider business mailing address

1540 ELK CREEK DR
IDAHO FALLS ID
83404-8322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-8393
  • Fax: 208-529-8398
Mailing address:
  • Phone: 208-529-8393
  • Fax: 208-529-8398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberP221
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901002356
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: