Provider Demographics
NPI:1619055878
Name:NOWAK, EUGENE JAMES (DO)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:JAMES
Last Name:NOWAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 FENTON ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-3516
Mailing Address - Country:US
Mailing Address - Phone:619-420-1840
Mailing Address - Fax:619-420-9630
Practice Address - Street 1:2440 FENTON STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3516
Practice Address - Country:US
Practice Address - Phone:619-420-1840
Practice Address - Fax:619-420-9630
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7103207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX71031Medicaid
F69692Medicare UPIN