Provider Demographics
NPI:1710076138
Name:NOWACKI, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:NOWACKI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1609 PASADENA AVE S
Mailing Address - Street 2:SUITE 4J
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4565
Mailing Address - Country:US
Mailing Address - Phone:727-347-4158
Mailing Address - Fax:727-345-2260
Practice Address - Street 1:1609 PASADENA AVE S
Practice Address - Street 2:SUITE 4J
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4565
Practice Address - Country:US
Practice Address - Phone:727-347-4158
Practice Address - Fax:727-345-2260
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
FLME0060591207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12884OtherBC/BS
FL21980510OtherWORKMAN'S COMP
FL2503431OtherGHI
FL3348283004OtherCIGNA
FL372504900Medicaid
FL593617364OtherBEECH STREET
FL4530901OtherAETNA