Provider Demographics
NPI:1992295950
Name:KOVACIC, MARK BRUNO (RN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BRUNO
Last Name:KOVACIC
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2737 WALSH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-0965
Mailing Address - Country:US
Mailing Address - Phone:408-228-8400
Mailing Address - Fax:
Practice Address - Street 1:2737 WALSH AVE
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-0965
Practice Address - Country:US
Practice Address - Phone:082-288-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA412765163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA412765OtherCA STATE BOARD OF NURSING