Healthcare Provider Details

I. General information

NPI: 1356311286
Provider Name (Legal Business Name): PAUL JEROME KOVALCIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 AMERICAN LEGION ROAD SUITE A
CHESAPEAKE VA
23321-5653
US

IV. Provider business mailing address

3105 AMERICAN LEGION ROAD SUITE A
CHESAPEAKE VA
23321-5653
US

V. Phone/Fax

Practice location:
  • Phone: 757-686-2687
  • Fax: 757-484-1682
Mailing address:
  • Phone: 757-686-2687
  • Fax: 757-484-1682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101032355
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: