Provider Demographics
NPI:1750380788
Name:NOVAK, GLENN JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JOSEPH
Last Name:NOVAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:51 WESTCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3902
Mailing Address - Country:US
Mailing Address - Phone:330-799-1718
Mailing Address - Fax:330-799-8328
Practice Address - Street 1:51 WESTCHESTER DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-3902
Practice Address - Country:US
Practice Address - Phone:330-799-1718
Practice Address - Fax:330-799-8328
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH003058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0766434Medicaid
OH0766434Medicaid
OH0530663Medicare ID - Type Unspecified