Healthcare Provider Details

I. General information

NPI: 1235132051
Provider Name (Legal Business Name): ADAM JASON MARCOVITCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 09/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 LOCUST LN
STATE COLLEGE PA
16801-5419
US

IV. Provider business mailing address

507 LOCUST LN
STATE COLLEGE PA
16801-5419
US

V. Phone/Fax

Practice location:
  • Phone: 814-237-4105
  • Fax:
Mailing address:
  • Phone: 814-237-4105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number200400909
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD429629
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8913722
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: