Provider Demographics
NPI:1114918737
Name:NOVACK, MARK ALAN (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:NOVACK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:224 SOUTH WOODS MILL RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017
Mailing Address - Country:US
Mailing Address - Phone:314-878-7220
Mailing Address - Fax:314-878-0047
Practice Address - Street 1:224 SOUTH WOODS MILL RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:314-878-7220
Practice Address - Fax:314-878-0047
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR6535207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A11069Medicare UPIN
MO002012890Medicare PIN