Provider Demographics
NPI:1669405742
Name:NOVOM, MARC JEFFREY (MD)
Entity type:Individual
Prefix:MR
First Name:MARC
Middle Name:JEFFREY
Last Name:NOVOM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10503 N STRATFORD PLACE
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092
Mailing Address - Country:US
Mailing Address - Phone:262-242-0155
Mailing Address - Fax:
Practice Address - Street 1:8989 N PORT WASHINGTON ROAD
Practice Address - Street 2:SUITE 122
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-351-6250
Practice Address - Fax:414-351-6465
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI210590202084N0400X
AZ314172084N0400X
FLME887012084N0400X
MN474422084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000002404Medicare ID - Type Unspecified
B55417Medicare UPIN