Provider Demographics
NPI:1366496572
Name:NOVOGRODER, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NOVOGRODER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3144
Mailing Address - Country:US
Mailing Address - Phone:201-836-4301
Mailing Address - Fax:201-530-7337
Practice Address - Street 1:704 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3144
Practice Address - Country:US
Practice Address - Phone:201-836-4301
Practice Address - Fax:201-836-5110
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10640612080P0205X
NJ25MA031387002080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC57015Medicare UPIN