Healthcare Provider Details

I. General information

NPI: 1730675117
Provider Name (Legal Business Name): DMITRI KOVALEV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 INNOVATION DR STE 350
GREENVILLE SC
29607-5269
US

IV. Provider business mailing address

PO BOX 631341
CINCINNATI OH
45263-1341
US

V. Phone/Fax

Practice location:
  • Phone: 864-516-1170
  • Fax: 877-249-9483
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number89512
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberBP10063903
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: