Basic Information
Provider Information | |||||||||
NPI: | 1427067586 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOVNAT | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 455 SAINT MICHAELS DR | ||||||||
Address2: |   | ||||||||
City: | SANTA FE | ||||||||
State: | NM | ||||||||
PostalCode: | 875057601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059896130 | ||||||||
FaxNumber: | 5058205408 | ||||||||
Practice Location | |||||||||
Address1: | 455 SAINT MICHAELS DR | ||||||||
Address2: |   | ||||||||
City: | SANTA FE | ||||||||
State: | NM | ||||||||
PostalCode: | 875057601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059896130 | ||||||||
FaxNumber: | 5058205408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2006 | ||||||||
LastUpdateDate: | 07/20/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200058 | NM | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 2000-58 | NM | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 2340234 | 01 |   | UHC | OTHER | 202018055 | 01 |   | PRESBYTERIAN HEALTH PLANS | OTHER | 69906 | 05 | NM |   | MEDICAID | QMP000003381633 | 01 |   | MOLINA | OTHER |