Provider Demographics
NPI:1558360131
Name:NOWAK, MICHAEL L (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:NOWAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 W COUNTRY CLUB RD
Mailing Address - Street 2:STE# 203
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5205
Mailing Address - Country:US
Mailing Address - Phone:575-624-4646
Mailing Address - Fax:575-625-8498
Practice Address - Street 1:350 W COUNTRY CLUB RD
Practice Address - Street 2:STE# 203
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5205
Practice Address - Country:US
Practice Address - Phone:575-624-4646
Practice Address - Fax:575-625-8498
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2619207V00000X
NMA-1602-11207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNPI & TIN#OtherBCBS OF NM
OH000000007795OtherANTHEM BCBS
OH0457349Medicaid
OH310884319026OtherCARESOURCE
OH2380630OtherCIGNA
OH160029113OtherRAILROAD MEDICARE PALMETT
NM40004279Medicaid
OH4341671OtherAETNA
OH2380630OtherCIGNA
NMNPI & TIN#OtherBCBS OF NM
NM40004279Medicaid