Provider Demographics
NPI:1124418058
Name:MIKHAIL NOVIKOV MD PC
Entity Type:Organization
Organization Name:MIKHAIL NOVIKOV MD PC
Other - Org Name:DR. NOVIKOV WELLNESS AND SKIN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-936-1657
Mailing Address - Street 1:10 THADDEUS MASON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-2284
Mailing Address - Country:US
Mailing Address - Phone:617-209-7823
Mailing Address - Fax:617-336-3306
Practice Address - Street 1:318 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532
Practice Address - Country:US
Practice Address - Phone:508-936-1657
Practice Address - Fax:888-355-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241998208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110109342AMedicaid