Provider Demographics
NPI:1013109198
Name:NOWAK, EDWARD J (LDO)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:J
Last Name:NOWAK
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3144 MARKWAY RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2925
Mailing Address - Country:US
Mailing Address - Phone:419-535-7683
Mailing Address - Fax:419-535-6704
Practice Address - Street 1:3144 MARKWAY RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2925
Practice Address - Country:US
Practice Address - Phone:419-535-7683
Practice Address - Fax:419-535-6704
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2005-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0297770001Medicare PIN