Provider Demographics
NPI:1154457513
Name:HALCOVAGE, JONATHAN PETER (DO)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PETER
Last Name:HALCOVAGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8135
Mailing Address - Country:US
Mailing Address - Phone:386-246-4096
Mailing Address - Fax:
Practice Address - Street 1:68 CLUBHOUSE DR
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8135
Practice Address - Country:US
Practice Address - Phone:386-246-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE63520Medicare UPIN