Provider Demographics
NPI:1790407682
Name:NOVA, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NOVA
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 1:5390 CAMINO SANTANDER APT 224
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-6518
Mailing Address - Country:US
Mailing Address - Phone:858-342-2160
Mailing Address - Fax:
Practice Address - Street 1:5390 CAMINO SANTANDER APT 224
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-6518
Practice Address - Country:US
Practice Address - Phone:858-342-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45588207N00000X, 207ND0900X
246ZB0301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No246ZB0301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherBiomedical Engineering