Provider Demographics
NPI:1396852059
Name:NOVAK, KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:NOVAK
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 1:1001 LAKESIDE AVE E
Mailing Address - Street 2:#1200
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3443 MEDINA RD
Practice Address - Street 2:#108
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5360
Practice Address - Country:US
Practice Address - Phone:216-524-7377
Practice Address - Fax:330-764-3074
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-073422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2185200Medicaid
OH2185200Medicaid
G77067Medicare UPIN