Provider Demographics
NPI:1730310418
Name:GREGORY D. NOVAK, M.D. P.C.
Entity Type:Organization
Organization Name:GREGORY D. NOVAK, M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-774-1693
Mailing Address - Street 1:1600 W UNIVERSITY AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3114
Mailing Address - Country:US
Mailing Address - Phone:928-774-1693
Mailing Address - Fax:928-774-3533
Practice Address - Street 1:1600 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3114
Practice Address - Country:US
Practice Address - Phone:928-774-1693
Practice Address - Fax:928-774-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41896207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438736Medicaid