Provider Demographics
NPI:1679564058
Name:NOWAK, CHARLES S (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
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:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-263-2600
Mailing Address - Fax:970-263-2692
Practice Address - Street 1:2020 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2914
Practice Address - Country:US
Practice Address - Phone:970-644-4220
Practice Address - Fax:970-263-4239
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO 48799207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01555022Medicaid
CO01555022Medicaid
CO01555022Medicaid