Basic Information
Provider Information | |||||||||
NPI: | 1669475083 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOVATIS | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 784 FRANKLIN AVE | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN LAKES | ||||||||
State: | NJ | ||||||||
PostalCode: | 074171306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8447770910 | ||||||||
FaxNumber: | 2015600712 | ||||||||
Practice Location | |||||||||
Address1: | 784 FRANKLIN AVE | ||||||||
Address2: |   | ||||||||
City: | FRANKLIN LAKES | ||||||||
State: | NJ | ||||||||
PostalCode: | 074171306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8447770910 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2005 | ||||||||
LastUpdateDate: | 12/02/2019 | ||||||||
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 | 174400000X | 25MA05561000 | NJ | N |   | Other Service Providers | Specialist |   | 207X00000X | 25MA05561000 | NJ | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207XX0004X | 25MA05561000 | NJ | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | P409968 | 01 | NJ | OXFORD # | OTHER | 5986397 | 01 | NJ | AETNA PPO # | OTHER | 200027488 | 01 | NJ | RR MDCR # | OTHER | 0817957 | 01 | NJ | AETNA HMO # | OTHER | 512961 | 01 | NJ | EMPIRE BC/BS # | OTHER |