Provider Demographics
NPI:1023227683
Name:NOVAKOVICH, PAUL M (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:M
Last Name:NOVAKOVICH
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 1:1200 S FARMERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5941
Mailing Address - Country:US
Mailing Address - Phone:318-255-3690
Mailing Address - Fax:318-251-6177
Practice Address - Street 1:1200 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5941
Practice Address - Country:US
Practice Address - Phone:318-255-3690
Practice Address - Fax:318-251-6177
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME108790207X00000X
LA205711207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL129805Medicaid
AL593-07447OtherBLUE CROSS BLUE SHIELD
AL593-07448OtherBLUE CROSS BLUE SHIELD
FL003720500Medicaid
FL14E9EOtherBLUE CROSS BLUE SHIELD
AL129809Medicaid
FLFI468ZMedicare PIN