MEDICARE: DR TED KOVACEV MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588215933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR TED KOVACEV MD PA

Provider Business Mailing Address
First Line	:	104 CIRCLE WAY ST STE A
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5200
Country	:	US
Telephone Number	:	979-721-7007
Fax Number	:	979-721-4254

Provider Business Practice Location Address
First Line	:	104 CIRCLE WAY ST STE A
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-5200
Country	:	US
Telephone Number	:	979-721-7007
Fax Number	:	979-721-4254

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MRS. DIANE BROOKE KOVACEV
Credential	:
Telephone Number	:	979-721-7007

Provider Enumeration Date	:	09/26/2019
Last Update Date	:	05/04/2022

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Directions to “DR TED KOVACEV MD PA ” Practice Location

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