Provider Demographics
NPI:1649387432
Name:NOWAK, PHILIP H (OD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:H
Last Name:NOWAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 GRAND VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-6123
Mailing Address - Country:US
Mailing Address - Phone:765-352-0835
Mailing Address - Fax:765-352-0881
Practice Address - Street 1:410 GRAND VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-6123
Practice Address - Country:US
Practice Address - Phone:765-352-0835
Practice Address - Fax:765-352-0881
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002922A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU69384Medicare UPIN