Provider Demographics
NPI:1043336381
Name:NOVAK, JACOB JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHN
Last Name:NOVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 961214
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-0214
Mailing Address - Country:US
Mailing Address - Phone:972-899-6666
Mailing Address - Fax:972-899-6665
Practice Address - Street 1:2628 LONG PRAIRIE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4839
Practice Address - Country:US
Practice Address - Phone:972-899-6666
Practice Address - Fax:972-899-6665
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK2766207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK2766OtherSTATE LICENSE
TXG55568Medicare UPIN