Provider Demographics
NPI:1265517635
Name:NOVICE, FRED MARK (MD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:MARK
Last Name:NOVICE
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 1:7456 PADDLEWHEEL CRT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301
Mailing Address - Country:US
Mailing Address - Phone:248-932-3376
Mailing Address - Fax:248-932-1046
Practice Address - Street 1:4120 WEST MAPLE ROAD
Practice Address - Street 2:SUITE 206
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301
Practice Address - Country:US
Practice Address - Phone:248-932-3376
Practice Address - Fax:248-932-1046
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406190207N00000X, 207ND0900X
OK16422207NI0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
06392341OtherBS
06392341OtherBS
E43987Medicare UPIN