Provider Demographics
NPI:1417904343
Name:NOWAK, ROGER B (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:B
Last Name:NOWAK
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 1:55 HIGH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03842-2213
Mailing Address - Country:US
Mailing Address - Phone:603-967-8033
Mailing Address - Fax:603-601-6040
Practice Address - Street 1:55 HIGH ST STE 301
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:NH
Practice Address - Zip Code:03842-2213
Practice Address - Country:US
Practice Address - Phone:603-770-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH10688207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3076273Medicaid
G70298Medicare UPIN
NH3076273Medicaid