Provider Demographics
NPI:1154458321
Name:NOVAK, RICHARD BOGUMIL (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BOGUMIL
Last Name:NOVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9627 WOODED PATH DR
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1088
Mailing Address - Country:US
Mailing Address - Phone:708-599-4108
Mailing Address - Fax:630-834-0319
Practice Address - Street 1:401 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-1218
Practice Address - Country:US
Practice Address - Phone:630-834-0132
Practice Address - Fax:630-834-0319
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH99037Medicare UPIN
IL208029Medicare ID - Type Unspecified