Provider Demographics
NPI:1598762924
Name:NOVACK, BRIAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:NOVACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29630 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092-1829
Mailing Address - Country:US
Mailing Address - Phone:440-944-6665
Mailing Address - Fax:
Practice Address - Street 1:29630 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WICKLIFFE
Practice Address - State:OH
Practice Address - Zip Code:44092-1829
Practice Address - Country:US
Practice Address - Phone:440-944-6665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2998-N213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH480031313OtherMEDICARE RAILROAD
OHDD0381OtherMEDICARE RAILROAD
OHP00269217OtherMEDICARE RAILROAD
OHCH5179OtherMEDICARE RAILROAD
OH2146270Medicaid
OHP00269217OtherMEDICARE RAILROAD
OH480031313OtherMEDICARE RAILROAD
OHU77040Medicare UPIN
OH4602080001Medicare NSC
OHDD0381OtherMEDICARE RAILROAD