Provider Demographics
NPI:1063584274
Name:KOVARIK, WENZEL D (MD)
Entity type:Individual
Prefix:
First Name:WENZEL
Middle Name:D
Last Name:KOVARIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-5922
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH21232207L00000X
MEMD14746207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3240685OtherAETNA
MEMN1444OtherHPHC
NH30201139Medicaid
ME332370099Medicaid
MEMM721501Medicare PIN
MEM130214OtherCIGNA
MEMM7215Medicare ID - Type Unspecified
MEMM721502Medicare PIN
MEMM721503Medicare PIN
ME036425OtherANTHEM
MEF34425Medicare UPIN
ME050058951Medicare ID - Type UnspecifiedRAILROAD