Basic Information
| Provider Information | |||||||||
| NPI: | 1093048019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOVOOR | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MBBS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193537123 | ||||||||
| FaxNumber: | 3193562220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 12/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01077141A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 01077141A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085N0700X | SP196 | IA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 201383550 | 05 | IN | MEDICAID |