Basic Information
| Provider Information | |||||||||
| NPI: | 1033226899 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOVTUNOVA | ||||||||
| FirstName: | SVETLANA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W | ||||||||
| Address2: | STE. 101 | ||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764000 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 2ND ST E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342081042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417465111 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/18/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 241331 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME126454 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BK9918838 | 01 | NY | DEA | OTHER | 11357A | 01 | NY | MEDICARE TYPE UNSPECIFIED | OTHER | 02810355 | 05 | NY | MEDICAID |