Provider Demographics
NPI:1750303913
Name:NOVAK, LARRY IRA (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:IRA
Last Name:NOVAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5112 WEST TAFT ROAD
Mailing Address - Street 2:SUITE L
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088
Mailing Address - Country:US
Mailing Address - Phone:315-452-2500
Mailing Address - Fax:315-452-2510
Practice Address - Street 1:4104 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6635
Practice Address - Country:US
Practice Address - Phone:315-663-0059
Practice Address - Fax:315-663-0123
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00482435Medicaid
NY56564GMedicare PIN
NY00482435Medicaid
NY080104359Medicare PIN
NYRA8170Medicare PIN