1750382966 NPI number — JOHNNY G KOVOOR

Table of content: JOHNNY G KOVOOR (NPI 1750382966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750382966 NPI number — JOHNNY G KOVOOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOVOOR
Provider First Name:
JOHNNY
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750382966
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 KIMBALL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YONKERS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10704-4221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-237-8282
Provider Business Mailing Address Fax Number:
914-237-8575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 KIMBALL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YONKERS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10704-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-237-8282
Provider Business Practice Location Address Fax Number:
914-237-8575
Provider Enumeration Date:
08/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  228788 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: 228788 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000095726 . This is a "GHI HMO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 228788 . This is a "HIP#" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1310P1 . This is a "EMPIRE BC/BS (YONKERS) #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02466448 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P2927478 . This is a "OXFORD#" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1310P12 . This is a "EMPIRE BC/BS (NEW YORK) #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5996377 . This is a "GHI PPO #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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