Provider Demographics
NPI:1689630808
Name:NOVICK, JASON LYLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:LYLE
Last Name:NOVICK
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 1:525 CAPITOLA AVE
Mailing Address - Street 2:UNIT B
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2759
Mailing Address - Country:US
Mailing Address - Phone:831-462-2132
Mailing Address - Fax:831-462-2930
Practice Address - Street 1:525 CAPITOLA AVE
Practice Address - Street 2:UNIT B
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2759
Practice Address - Country:US
Practice Address - Phone:831-462-2132
Practice Address - Fax:831-462-2930
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4661213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00363267OtherRAIL ROAD MEDICARE GROUP MEMBER PTAN
CA000E46610Medicare PIN
CA5739670001Medicare NSC