Provider Demographics
NPI:1477537264
Name:NOWICKI, STEPHEN T (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:T
Last Name:NOWICKI
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1207 FAIRCHILD CT
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4321
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-669-5627
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA078949208000000X
CAA789492080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH93901Medicare UPIN
CA00A789492Medicare PIN