Provider Demographics
NPI:1750411427
Name:EUGENE J NOWAK DO INC
Entity type:Organization
Organization Name:EUGENE J NOWAK DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NOWAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-420-1840
Mailing Address - Street 1:PO BOX 210160
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91921-0160
Mailing Address - Country:US
Mailing Address - Phone:619-420-1840
Mailing Address - Fax:619-420-9630
Practice Address - Street 1:2440 FENTON ST.
Practice Address - Street 2:101
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914
Practice Address - Country:US
Practice Address - Phone:619-420-1840
Practice Address - Fax:619-420-9630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7103207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX71030Medicaid
CA20A7103Medicare ID - Type Unspecified
CA00AX71030Medicaid