Provider Demographics
NPI:1013053586
Name:NOWAK, RONALD JOSEPH
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:JOSEPH
Last Name:NOWAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13734 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3751
Mailing Address - Country:US
Mailing Address - Phone:586-773-8260
Mailing Address - Fax:586-773-7940
Practice Address - Street 1:13734 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3751
Practice Address - Country:US
Practice Address - Phone:586-773-8260
Practice Address - Fax:586-773-7940
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540E00825OtherBLUE CROSS BLUE SHIELD
MI0453690001Medicare ID - Type Unspecified